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how does fluid restriction/dehydration impact electrolytes

Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion.

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? Calcium Sodium Chloride Potassium

Correct response: Sodium Explanation: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium should not restrict their intake of sodium and should drink adequate amounts of fluid each day. Calcium, chloride, and potassium are important for normal body functions but sodium is most important to the absorption of lithium.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? The client voids 500 mL of urine. The client tolerates eating a hamburger. The client is pain free. The client walks in the hallway unassisted.

Correct response: The client voids 500 mL of urine. Explanation: Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable, and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the client should be able to sit up and go to the bathroom without assistance.

A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? back abdomen fundus perineum

Correct response: perineum Explanation: A pudendal block is used for vaginal births to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. A pudendal block relieves pain in the perineum and vagina. It does not relieve discomfort in the back, abdomen, or fundus.

A client who has had the jaws wired begins to vomit. The nurse should first: insert a nasogastric (NG) tube and connect it to suction. use wire cutters to cut the wire. suction the client's airway as needed. administer an antiemetic intravenously.

Correct response: suction the client's airway as needed. Explanation: The nurse's first action is to clear the client's airway as necessary. Inserting an NG tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest.

A 4-year-old child is brought to the clinic for a checkup. It is determined that the family does not have fluoridated water. The nurse should give which instruction about using fluoride supplements? Give with meals. Be sure to take the supplement with milk. Do not eat or drink for 30 minutes after the supplement. Have the child swallow the tablet immediately after putting it in the mouth.

Do not eat or drink for 30 minutes after the supplement. Explanation: Fluoride supplements should be administered on an empty stomach. No food or fluids should be ingested for 30 minutes after taking the supplement. Fluoride should not be given with calcium-rich foods. A 4-year-old child would probably not be able to take a tablet. A child who is able should chew the tablet and swish the pieces for 30 seconds before swallowing.

A health care provider (HCP) prescribes a lengthy x-ray examination for a client with osteoarthritis. Which action by the nurse would demonstrate client advocacy? Contact the X-ray department, and ask the technician if the lengthy session can be divided into shorter sessions. Contact the HCP to determine if an alternative examination could be scheduled. Request a prescription for acetaminophen prior to the examination. Request padding for the hard x-ray table.

Contact the X-ray department, and ask the technician if the lengthy session can be divided into shorter sessions. Explanation: Shorter sessions will allow the client to rest between the sessions. Changing the HCP's prescription to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent; thus it would not help this client avoid the adverse effects of a lengthy x-ray examination. Although the x-ray table is hard, it is not possible to provide padding and obtain the needed diagnostic x-rays.

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? "Don't eat anything for 12 hours before the test." "Don't shampoo your hair for 24 hours before the test." "Avoid stimulants and alcohol for 24 to 48 hours before the test." "Avoid thinking about personal matters for 12 hours before the test."

Correct response: "Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." "Try to ambulate independently after about 24 hours." "Shampoo your hair every day for 10 days to help prevent ear infection." "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

Correct response: "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." Explanation: The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother? "Clean his face and diaper area for 2 weeks." "Use sterile sponges to cleanse the inguinal incision." "Give him a sponge bath daily for 1 week." "Give the infant full tub baths every day."

Correct response: "Give him a sponge bath daily for 1 week." Explanation: The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. Cleaning the infant's face and diaper area should occur at least daily and continuously, not limited to a 2-week period. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days. Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable. Because the incision must be kept as clean and dry, full tub baths are inappropriate.

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? "Gloves help protect you against infectious organisms." "Gloves guard you against my cold hands." "Gloves may protect me against infectious organisms." "Gloves are required for standard precautions."

Correct response: "Gloves are required for standard precautions." Explanation: Wearing gloves whenever exposure to blood or body fluids is anticipated is a standard precaution recommended by the Centers for Disease Control and Prevention. Although gloves protect both the client and the nurse from infectious organisms and guard against the nurse's cold hands, the nurse wears them primarily to maintain standard precautions, which is required by the Occupational Safety and Health Administration.

The nurse recognizes the client in the emergency department from a picture in the local paper. The client has recently received a major scholarship for high academic achievement. The client tells the nurse that he hears voices that tell him he is worthless. He has tried to kill himself. What statement is the most appropriate for the nurse to use first when attempting to establish a therapeutic relationship? "You have a lot to live for." "The voices are not real." "I am sorry this is happening to you." "Would you like me to call your parents?"

Correct response: "I am sorry this is happening to you." Explanation: Demonstrating empathy is an effective means of beginning an effective therapeutic relationship. Challenging the client's beliefs or thoughts is not the most effective in establishing a trusting relationship. Determining what supports are needed is done after an initial assessment.

Which client statement indicates the need for additional teaching about benzodiazepines? "I cannot drink alcohol while taking diazepam." "I can stop taking the drug anytime I want." "Diazepam can make me drowsy, so I should not drive for a while." "Diazepam will help my tight muscles feel better."

Correct response: "I can stop taking the drug anytime I want." Explanation: Diazepam, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly tapered off of the medication to decrease withdrawal symptoms, which would be similar to withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased central nervous system depressant effect and therefore should be avoided. Diazepam can cause drowsiness, and the client should be warned about driving until tolerance develops. Diazepam has muscle relaxant properties and will help tight, tense muscles feel better.

The nurse is teaching a new prenatal client about her iron-deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? "I will need to take iron supplements now." "I may have anemia because my family is of Asian descent." "I am considered anemic if my hemoglobin is below 11 g/dl (110 g/l)." "The anemia increases the workload on my heart."

Correct response: "I may have anemia because my family is of Asian descent." Explanation: Iron-deficiency anemia is caused by insufficient iron stores in the body, poor iron content in the diet of the pregnant woman, or both. Other thalassemias and sickle-cell anemia, rather than iron-deficiency anemia, can be associated with ethnicity but occur primarily in clients of African or Mediterranean origin. Because red blood cells increase by about 50% during pregnancy, many clients will need to take supplemental iron to avoid iron-deficiency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dl (110 g/l). In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells.

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

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

When developing the teaching plan for an adolescent with insulin-dependent diabetes, what should the nurse include about the relationship among exercise, diet, and insulin? "Before running, inject your insulin into the leg muscle for quicker absorption." "If your blood glucose is 240 mg/dL (13.3 mmol/L) or above, do not run." "You will need to take extra insulin before you go running." "Do not eat your snack before running, because you will get a stomachache."

Correct response: "If your blood glucose is 240 mg/dL (13.3 mmol/L) or above, do not run." Explanation: Strenuous exercise, such as running, should be avoided if the adolescent's blood glucose level is 240 mg/dL (13.3 mmol/L) or above because it places the client at risk for hypoglycemia. When insulin levels are not adequate, the cells cannot receive glucose, even though the blood glucose level is high. With low insulin levels, glucagons act to increase hepatic glucose production, thus raising the blood glucose level, which cannot be used at the muscle site. Taking extra insulin prior to strenuous exercise also increases the risk of hypoglycemia. Vigorous muscle contraction increases local blood flow and absorption of insulin injected into that area. Because exercise decreases blood glucose levels, snacks should be given before strenuous exercise to prevent hypoglycemia. If the adolescent cannot tolerate the extra needed food, insulin dosage may have to be reduced.

A nurse is preparing a delusional client for a computed tomography scan of the brain to rule out an organic etiology. As the nurse accompanies the client to the radiology department, he looks around anxiously and states, "The Interpol is coming to kill me." What is the nurse's best response? "The Interpol isn't here." "Your illness is causing you to hear voices." "It sounds like you're frightened." "No one can hurt you here."

Correct response: "It sounds like you're frightened." Explanation: Even though the client's thinking processes are distorted and irrational, his feelings are very real. The nurse should intervene by empathizing with his emotions. Assuring the client that the Interpol isn't present, telling the client that his illness is causing him to hear voices, and telling him that no one can hurt him appeal to the logical reasoning his illness has impaired. These responses may increase his anxiety by denying the reality of his current emotional experience.

A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which instruction is most important for the nurse to include in the client's teaching plan? "Maintain a moderate exercise program." "Rest as much as possible." "Lose weight." "Jog at least 2 miles (3.2 kilometers) per day."

Correct response: "Maintain a moderate exercise program." Explanation: The nurse should instruct the client to maintain a moderate exercise program. Such a program helps strengthen bones and prevents the bone loss that occurs from excess parathyroid hormone. Walking or swimming provides the most beneficial exercise. Because of weakened bones, a rigorous exercise program such as jogging is contraindicated. Weight loss might be beneficial but it isn't as important as developing a moderate exercise program.

A multigravid client admitted to the labor area is scheduled for a cesarean birth under spinal anesthesia. Which client statement indicates teaching about spinal anesthesia has been understood? "The medication will be administered while I am in prone position." "The anesthetic may cause a severe headache, which is treatable." "My blood pressure may increase if I lie down too soon after the injection." "I can expect immediate anesthesia that can be reversed very easily."

Correct response: "The anesthetic may cause a severe headache, which is treatable." Explanation: Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a "spinal headache" caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in a flat position, or using a blood patch that can clot and seal off any further leakage of fluid. Spinal anesthesia is administered with the client in a sitting position or side lying. Another adverse effect of spinal anesthesia is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20 to 30 minutes. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1 to 2 hours to wear off.

fter teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the parent makes which statement? "There is no rectal opening for stool to pass." "There is a tube between the trachea and esophagus." "The nerves at the end of the large colon are missing." "The muscle below the stomach is too tight."

Correct response: "The nerves at the end of the large colon are missing." Explanation: The primary defect in Hirschsprung's disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are missing. Absence of a rectal opening refers to an imperforate anus. A tube between the trachea and esophagus refers to a tracheoesophageal fistula. Presence of a tight muscle below the stomach refers to pyloric stenosis.

A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? "You are experiencing leg pain because of venous congestion." "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs." "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." "The pain is related to atherosclerosis that is the same problem causing your angina."

Correct response: "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." Explanation: When there is a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency. This results in inadequate provision of oxygenated blood to the muscles when there is an increase in muscle demand. This results in the pain of intermittent claudication. The other choices refer to problems with venous congestion rather than arterial perfusion. That the pain is related to atherosclerosis does not explain the specific reason for the pain.

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate? "This subject seems to be troubling you. Let's walk to the activity room." "Describe the man who's out to get you. What does he look like?" "There is no reason to be afraid of that man. This hospital is very secure." "There is no need to be concerned about a man who isn't even real."

Correct response: "This subject seems to be troubling you. Let's walk to the activity room." Explanation: This remark distracts the client from the delusion by engaging him in a less-threatening or more-comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the client's false belief. The other options focus on the content of the delusion rather than on the meaning, feeling, or distress it evokes.

The daughter of a client with Alzheimer's disease tells the nurse that her mother thinks someone is stealing her things. Which response by the nurse would be most helpful? "That behavior is typical of people with Alzheimer's disease and will become worse." "Your mother has problems with remembering where she puts things." "We have checked her room and nothing was missing?" "We asked the health care provider to evaluate your mother for paranoid delusions, which are common in people with Alzheimer's disease."

Correct response: "We asked the health care provider to evaluate your mother for paranoid delusions, which are common in people with Alzheimer's disease." Explanation: The best response addresses the daughter's concern and explains that paranoia and delusions are common in Alzheimer's disease. Stating that the behavior is typical of someone with Alzheimer's disease dismisses the daughter, is not helpful, and does not increase the daughter's knowledge about the disease. While it is important to share the information that the client's perceptions are not based in reality, telling the daughter that nothing is missing doe not address the underlying client problem. These are not delusions or her imagination but a reaction to not being able to remember.

The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following statements made by the nurse would not be accurate about the involuntary admission process? "You're in the hospital because the psychiatrist who saw you earlier thinks that you are unable to care for yourself right now." "You're free to talk to a lawyer if you'd like to do so." "You cannot leave the hospital until the primary health care provider thinks you can take care of yourself." "You cannot have any visitors while you're here involuntarily."

Correct response: "You cannot have any visitors while you're here involuntarily." Explanation: Clients have a right to see visitors regardless of admission status. Involuntary hospitalization requires a psychiatrist state-of-need. Any client admitted involuntarily has the right to legal counsel. The client's release requires medical approval.

The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? 1 week 2 to 4 weeks 5 to 7 weeks 8 weeks

Correct response: 2 to 4 weeks Explanation: Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client? Perform gastric lavage Obtain blood work Administer IV fluid Administer acetylcysteine

Correct response: Administer acetylcysteine Explanation: If the client is seen within one hour of ingestion, activated charcoal can be given to prevent absorption, or gastric lavage can be used. Blood work would be obtained but wouldn't be the first priority. Intravenous fluids would also be administered, but administering ?-acetylcysteine, the specific antidote for acetaminophen poisoning, is the priority.

A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? Do not allow the client to ingest fluids. Encourage the client to drink at least 500 mL of water each hour. Request the central supply department to send supplies for straining urine. Administer an opioid analgesic as prescribed.

Correct response: Administer an opioid analgesic as prescribed. Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management.

Which factors are major components of a client's general background history? Allergies and socioeconomic status Urine output and allergies Gastric reflex and the client's age Bowel habits and allergies

Correct response: Allergies and socioeconomic status Explanation: General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

A client has an abnormal result on a Papanicolaou test. The client asks the nurse what dysplasia means. Which definition should the nurse provide? Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin Increase in the number of normal cells in a normal arrangement in a tissue or an organ Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found Alteration in the size, shape, and organization of differentiated cells

Correct response: Alteration in the size, shape, and organization of differentiated cells Explanation: The nurse should explain that dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.

A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? Altered nutrition (less than body requirements) related to difficulty sucking Parental sleep pattern disturbance related to the baby's feeding schedule Knowledge deficit related to normal infant growth and development Altered role performance related to new responsibilities within the family

Correct response: Altered nutrition (less than body requirements) related to difficulty sucking Explanation: The nurse's initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? Acupuncture An exercise routine that includes range-of-motion (ROM) exercises Heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) Cold therapy

Correct response: An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

A nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site should the client use? Deltoid Rectus femoris Vastus lateralis Anterior aspect of the thigh

Correct response: Anterior aspect of the thigh Explanation: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites.

A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed? Assign her to the labor and delivery area. Assign her to the nursery. Use her as a nursing assistant in the postpartum unit. Assign her a client care assignment in the postpartum unit.

Correct response: Assign her a client care assignment in the postpartum unit. Explanation: The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can safely use her nursing skills and doesn't need to assume the role of a nursing assistant. The staff-shared nurse isn't qualified to work in the labor and delivery area or the nursery because both require specialized training to safely administer care.

Which is the priority intervention for a preschool child with epiglottiditis and a deteriorating respiratory status? Administering oxygen by face mask Administering parenteral antibiotics Assisting with intubation Monitoring the electrocardiogram for arrhythmias

Correct response: Assisting with intubation Explanation: The most important intervention for a child with epiglottiditis is airway management because children are at high risk for developing abrupt airway obstruction. Therefore, intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they will never allow a mask to stay in place. Provide humidified "blow-by" oxygen administered by the parent if possible. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management.

A nurse is caring for a client 24 hours after an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What should the nurse do first? Auscultate for bowel sounds. Ask the client if he feels hunger or gas pains. Consult the dietician. Encourage the wife to bring the soup.

Correct response: Auscultate for bowel sounds. Explanation: The nurse should perform a thorough assessment of the abdomen and auscultate for bowel sounds in all four quadrants. Clients who have gastrointestinal surgery may have decreased peristalsis for several days after surgery. The nurse should check the abdomen for distention and check with the client and the medical record regarding the passage of flatus or stool. Consulting a dietician would be inappropriate because the client must be kept on nothing-by-mouth status until bowel sounds are present. The nurse should explain to the wife that it is too soon after surgery for her husband to eat.

A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? Call for both clients' blood transfusions at the same time. Ask another nurse to verify the compatibility of both units at the same time. Call for and hang the first client's blood transfusion. Ask another nurse to call for and hang the blood for the second client.

Correct response: Call for and hang the first client's blood transfusion. Explanation: When two clients are to receive blood at the same time, the nurse should call for and hang the clients' transfusions separately to avoid error. The nurse should call for and hang the first client's blood first because this client has experienced a change in blood pressure over a short period of time. The nurse should next call and hang the second client's blood transfusion as there is no indication that this client is unstable at this time. The nurse should not call for both units of transfusions at the same time due to the increased risk of misidentification. The nurse should not verify compatibility of both units at the same time due to the increased risk of misidentification. It is not necessary to involve two nurses because the second client can wait until the nurse has time to hang the blood.

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin? Tetracyclines Aminoglycosides Erythromycin Cephalosporins

Correct response: Cephalosporins Explanation: A client who is allergic to cephalosporins may also be allergic to penicillin. For the same reason, penicillin must be used cautiously in clients who are allergic to cephamycins, griseofulvin, or penicillamine. Cross-sensitivity between penicillin and tetracyclines, aminoglycosides, and erthyromycins hasn't been observed.

A client complains of difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take next? Dissolve the capsule in a full glass of water. Break the capsule and mix the contents with applesauce. Withhold the medication. Check for availability of a liquid preparation.

Correct response: Check for availability of a liquid preparation. Explanation: The nurse should find out whether the medication is available in liquid form. Dissolving or breaking the capsule may interfere with drug action or absorption. The nurse shouldn't withhold any medication without first notifying the physician.

The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which action would be most important for the nurse to include in pretest preparation? Ensure adequate fluid intake on the day of the test. Prepare the client for the possibility of bladder spasms during the test. Check the client's history for allergy to iodine. Determine when the client last had a bowel movement.

Correct response: Check the client's history for allergy to iodine. Explanation: A client scheduled for an IVP should be assessed for allergies to iodine and shellfish. Clients with such allergies may be allergic to the IVP dye and be at risk for an anaphylactic reaction. Adequate fluid intake is important after the examination. Bladder spasms are not common during an IVP. Bowel preparation is important before an IVP to allow visualization of the ureters and bladder, but checking for allergies is most important.

A nurse has received change-of-shift report on the following four clients. Which client should the nurse assess first? Client with right-sided heart failure who has 4+ bilateral edema in the legs and feet Client with a recent lung transplant scheduled to begin pulmonary rehabilitation Client with a pleural effusion who has severe stabbing chest pain Client experiencing tracheal deviation following a subclavian catheter insertion

Correct response: Client experiencing tracheal deviation following a subclavian catheter insertion Explanation: Tracheal deviation suggests possible tension pneumothorax, which is a medical emergency and needs to be evaluated immediately. Edema is a client with right sided heart failure is a chronic condition and expected, it is not an emergency. Stabbing chest pain is expected with a pleural effusion and is also not an emergency situation. Pulmonary rehabilitation is completed by respiratory therapy and does not require the attention of the nurse.

A client on the behavioral health unit spends several hours per day organizing and reorganizing his closet. He repeatedly checks to see if his clothing is arranged in the proper order. What term is commonly used to describe this behavior? Obsession Compulsion Exhibitionism Transference

Correct response: Compulsion Explanation: Compulsion is present when a client performs recurrent, persistent, repetitive actions and behaviors that he feels driven to perform. This behavior interferes with the client's activities of daily living and disrupts his lifestyle. These compulsions relieve the intense anxiety that the client experiences when he doesn't act on them. Obsession is a recurrent, persistent, and intrusive thought. Exhibitionism is the compulsive need to expose a part of one's body, especially the genitals, to an unsuspecting stranger. Transference is the process of projecting one's feelings and thoughts onto the therapist, who symbolically represents a significant person in the client's past.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? Continue to assess the client, allowing the officer to assume responsibility for the restraint. Call the supervisor and report the officer's decision to keep the cuffs on. Ask the physician for an order to remove the handcuffs. Refuse to provide care while the client is handcuffed to the stretcher.

Correct response: Continue to assess the client, allowing the officer to assume responsibility for the restraint. Explanation: In this situation, the police officer has applied the restraint and has taken responsibility for the restraint. The nurse should assess the client for any potential complication from the handcuffs, document the assessment, and provide care to the client as usual. The other options are incorrect because the police officer has assumed responsibility for the restraint. It is unlikely that a physician would order the restraint to be removed against the officer's recommendation, and if the restraints are in place and the officer is present, the nurse can provide care to the client.

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test? The amount of dexamethasone in the system Cortisol levels after the system is challenged Changes in certain body chemicals, which are altered in depression Cortisol levels before and after the system is challenged with a synthetic steroid

Correct response: Cortisol levels before and after the system is challenged with a synthetic steroid Explanation: The dexamethasone suppression test measures cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test does not measure dexamethasone or body chemicals altered in depression. Dexamethasone is used to challenge the cortisol level.

A nurse is teaching child care classes for adolescent mothers. To enhance the adolescents' understanding of infant safety, the nurse would suggest that the mother: discuss infant safety with the pediatrician. review a video about pregnancy prevention. Crawl around on the floor looking for cotential hazards from the eyes of an infant. attend a lecture about poison control.

Correct response: Crawl around on the floor looking for cotential hazards from the eyes of an infant. Explanation: Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective. The nurse doesn't need to instruct adolescents to discuss infant safety with the pediatrician because the nurse can provide such information in the class environment. Presenting a lecture or video doesn't directly focus on the infant's perspective regarding items that may be a safety threat.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? Talking with the client's family about his angry feelings Performing an assessment for tardive dyskinesia Learning to effectively express needs to staff and others Demonstrating control over aggressive behavior

Correct response: Demonstrating control over aggressive behavior Explanation: The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first? Cut off the client's clothing and dispose of them in hazardous waste containers Place the fully clothed client in a shower for decontamination Determine what decontamination measures took place in the field before approaching the client Discharge or admit all current clients in the emergency department

Correct response: Determine what decontamination measures took place in the field before approaching the client Explanation: . During a disaster the nurse's priority is personal safety. Determining what decontamination measures have already taken place will inform the nurse of necessary precautions. The nurse should not cut off the clothing or place the client in the shower until an assessment of the hazardous material has been completed. Containing the exposed clients in one area, free from other clients, is important, but the safety of the healthcare workers is the priority.

A nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority? Checking client pain levels for report to the next shift nurse Checking to see that client orders have been transcribed Documenting the care provided during the shift Completing input and output recording for the shift

Correct response: Documenting the care provided during the shift Explanation: Documentation should take top priority as this is the only way the nurse can legally claim that client interventions were performed. Checking client pain levels should be done throughout the shift and clients should be medicated so that they are not in need during busy change of shift times. Waiting until the end of the shift to review that client orders have been transcribed may lead to a delay in treatment and should be completed in a timely manner throughout the shift. Completing input and output recording can be assigned to a nurse assistant and should be delegated.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? Encourage a high-calorie, high-protein diet. Restrict fluids to 1,500 ml per day. Limit salt intake to 2 g per day. Encourage foods high in vitamin B.

Correct response: Encourage a high-calorie, high-protein diet. Explanation: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

Which instruction should a nurse give to a client who's 26 weeks pregnant and complains of constipation? Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. Tell her to ask her caregiver for a mild laxative. Suggest the use of an over-the-counter stool softener. Tell her to go to the evaluation unit because constipation may cause contractions.

Correct response: Encourage her to increase her intake of roughage and to drink at least six glasses of water per day. Explanation: The best instruction is to encourage the client to increase her intake of high-fiber foods (roughage) and to drink at least six glasses of water per day. Mild laxatives and stool softeners may be needed, but dietary changes should be tried first. Although straining during defecation and diarrhea can stimulate uterine contractions, telling the client to go to the evaluation unit doesn't address her concern.

A health care provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid? Follow-up blood tests are necessary while on this medication. The extended-release tablet can be crushed if necessary for ease of swallowing. Tachycardia and upset stomach are common side effects. Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning.

Correct response: Follow-up blood tests are necessary while on this medication. Explanation: Valproic acid can cause hepatotoxicity, so regular liver function tests are needed. Other side effects include nausea and drowsiness. Extended-release tablets should not be split or crushed; doing so changes their absorption. Alcohol should never be mixed with this medication. There will be medication in the client's body at all times. Nausea and tachycardia are not common side effects of valproic acid.

A nursery nurse just received the shift report. Which neonate should the nurse assess first? Four-hour-old term neonate with jaundice Two-day-old term neonate in an open bassinette Six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation Twelve-hour-old term neonate who is small for gestational age

Correct response: Four-hour-old term neonate with jaundice Explanation: The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse.

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

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

Which of the following should the nurse include in the teaching plan for the parents of a child who is receiving methylphenidate? Give the medication at the same time every evening. Have the child take two doses at the same time if the last dose was missed. Give the single-dose form of the medication early in the day. Allow concurrent use of any over-the-counter medications with this drug.

Correct response: Give the single-dose form of the medication early in the day. Explanation: The single-dose form of methylphenidate should be taken 10 to 14 hours before bedtime to prevent problems with insomnia, which can occur when the daily or last dose of the medication is taken within 6 hours (for multiple dosing) or 10 to 14 hours (for single dosing) before bedtime. It is recommended that a missed dose be taken as soon as possible; the dose is skipped if it is not remembered until the next dose is due. methylphenidate (Ritalin) is tx for ADHD

A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect: thyroiditis. Graves' disease. Hashimoto's thyroiditis. multinodular goiter.

Correct response: Graves' disease. Explanation: Graves' disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-aged females. In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, radioactive iodine uptake is low (?2%), and a client with a multinodular goiter will show an uptake in the high-normal range (3% to 10%)

A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the receipt of a divorce notice. Which client finding indicates to the nurse that the client is ready for discharge? Expresses a readiness for discharge. Has the names and phone numbers of two divorce lawyers. Has a list of support persons and community resources. Displays emotional stability.

Correct response: Has a list of support persons and community resources. Explanation: The risk of suicide can persist for 2 to 3 months even after a crisis has abated. Therefore, it is important for the client to be able to verbalize information about appropriate support persons and community resources and to have this information readily available. Although the client may state that she is ready to be discharged, this is not the most reliable indicator. A divorce lawyer may not be appropriate at this point. At 3 days after a suicide attempt, emotional stability is not likely.

A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? I.V. tubing with a volume-control chamber I.V. tubing with a macrodrip chamber I.V. tubing with a special filter Standard I.V. tubing used for adults

Correct response: I.V. tubing with a volume-control chamber Explanation: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.

A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms? Terbutaline Oxytocin Magnesium sulfate Calcium gluconate

Correct response: Magnesium sulfate Explanation: Magnesium sulfate is the drug of choice to treat hypertension of pregnancy because it reduces edema by causing a shift from the extracellular spaces into the intestines. It also depresses the central nervous system, which decreases the incidence of seizures. Terbutaline is a smooth muscle relaxant used to relax the uterus. Oxytocin is the synthetic form of the pituitary hormone used to stimulate uterine contractions. Calcium gluconate is the antagonist for magnesium toxicity.

The community psychiatric nurse conducts a weekly education group for clients in a senior citizen day program. The nurse suspects that one of the clients with cognitive impairment is experiencing abuse in the home where she lives with a middle-aged child. The client has suspicious bruises on her body and tells the nurse she often falls at home. What would be the priority care plan for this client by the nurse? Make an immediate appointment to visit the home to assess the situation. Alert the physician. Encourage the installation of railings and raised toilet seats in the home. Wait a few weeks to assess whether there are additional bruises.

Correct response: Make an immediate appointment to visit the home to assess the situation. Explanation: Older adults are at high risk for abuse and violence in the home, particularly when there is cognitive impairment. The first step for the nurse is to assess the client's home environment. To disregard the injuries by simply encouraging hand railings does not allow for a sufficient assessment of the situation/causation. Alerting the physician will not be effective without a fuller assessment. Waiting a few weeks could be considered negligent behavior of th

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Correct response: Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea (feces and its contents are quite alkalotic), lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

A nurse working in the emergency department enters the room of a client who is agitated and swears at the nurse. The client stands up and moves toward the nurse in an aggressive fashion. What is the most appropriate action by the nurse to address this situation? Move toward the door and leave to call the crisis response team. Stand firmly in place and be ready to defend against a possible blow. Talk calmly, reminding the client that the nurse is an advocate. Yell for help while trying to restrain the client.

Correct response: Move toward the door and leave to call the crisis response team. Explanation: The nurse assesses and identifies that the nurse's safety is at risk because the client is agitated and moving aggressively toward the nurse. The nurse needs to leave and obtain help in the form of a crisis response team. The other options are incorrect because they do not provide for the safety of the nurse or the client.

A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation? Notify the local Child Protective Services. Continue to observe the behavior of the child. Discuss the child's behavior with the parents. Advise the child that the inappropriate behavior must stop.

Correct response: Notify the local Child Protective Services. Explanation: If a nurse suspects abuse of any nature, it must be reported to the appropriate authorities, such as Child Protective Services. The other options are incorrect because they do not demonstrate the required action of the nurse in this situation.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. Notify the physician and security immediately. Ask the nursing assistant to dispose of the marijuana so that the client can't smoke anymore.

Correct response: Notify the physician and security immediately. Explanation: The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security because they're specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen, and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? Move to the entrance of the hospital and check each person leaving. Go to the obstetrics unit to determine if they need help with the situation. Call the nursery to ask which baby is missing. Observe individuals in the area for large bags or oversized coats.

Correct response: Observe individuals in the area for large bags or oversized coats. Explanation: The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be a responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.

While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slip into the acetabulum. The nurse interprets this positive finding as: Barlow's test. Galeazzi sign. Ortolani's sign. Trendelenburg's sign.

Correct response: Ortolani's sign. Explanation: Ortolani's sign refers to the "click" made when the femoral head slips forward into the acetabulum when forward pressure is exerted from behind the greater trochanter and the knee is held laterally. This sign indicates hip dislocation. A positive Barlow's test, evidenced by the femoral head slipping out over the acetabulum when pressure is applied then slipping back into place when the pressure is released, indicates that the hip is unstable with increased risk of dislocation. Galeazzi's sign refers to shortening of the affected limb in congenital hip dysplasia. It is elicited by flexing the infant's hips and knees while the infant lies supine. The soles of the feet are placed flat near the buttocks, and the knee heights are assessed for equality. Trendelenburg's sign refers to a downward tilting of the pelvis toward the normal side when a child with a dislocated hip stands on the affected side with the uninvolved leg elevated.

A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What prescription should the nurse implement first? Initiate intake/output record. Place an intravenous line. Position on the left side. Insert a nasogastric tube.

Correct response: Place an intravenous line. Explanation: Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable.

A nurse's assessment of a 6-month-old infant reveals a respiratory rate of 52 breaths/minute, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which action would be most appropriate? Administer a nebulizer treatment. Send the infant for a chest radiograph. Refer the infant to the emergency department. Provide teaching about cold care to the mother.

Correct response: Refer the infant to the emergency department. Explanation: Based on the assessment findings of increased respiratory rate, retractions, and wheezing, this infant needs further evaluation, which could be obtained in an emergency department. Without a definitive diagnosis, administering a nebulizer treatment would be outside the nurse's scope of practice unless there was a prescription for such a treatment. Sending the infant for a radiograph may not be in the nurse's scope of practice. The findings need to be reported to a HCP who can then determine whether or not a chest radiograph is warranted. The infant is exhibiting signs and symptoms of respiratory distress and is too ill to send out with just instructions on cold care for the mother.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? Respecting the client's desire to have the uncle make choices on her behalf. Revisiting the decision when the uncle is not present at the bedside. Teaching the client about her right to autonomy. Holding a family meeting and encouraging the client to speak on her own behalf.

Correct response: Respecting the client's desire to have the uncle make choices on her behalf. Explanation: The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis? Risk for impaired skin integrity Constipation Ineffective thermoregulation Risk for imbalanced nutrition: More than body requirements

Correct response: Risk for impaired skin integrity Explanation: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause Ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.

Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task? Scheduling staff assignments for the next month Terminating a nursing assistant for insubordination Deciding on salary increases for nurses after they complete orientation Telling a staff nurse to initiate disciplinary action against one of her peers

Correct response: Scheduling staff assignments for the next month Explanation: Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room? Transfer the client to a cart with manually suspended traction. Call the surgeon to request a prescription to temporarily remove the traction. Send the client on the bed with extra help to stabilize the traction. Remove the traction, and send the client on a cart.

Correct response: Send the client on the bed with extra help to stabilize the traction. Explanation: The nurse should send the client to the operating room on the bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.

A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality? Throw the documents in the trash can. Shred the documents or place them in a container to protect confidentiality. Place the documents in the client's chart. Leave the documents at the nurses' station.

Correct response: Shred the documents or place them in a container to protect confidentiality. Explanation: Kardexes, care plans, and other client documents contain confidential client information. The nurse should shred them or place them in a special confidential container for proper disposal. Regular garbage isn't secure and isn't an appropriate place to dispose of documents containing a client's name and information. Leaving the documents at the nurses' station may allow others to view them. It isn't necessary to place the nursing Kardex and care plan in the client's chart when the nurse has finished using them.

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. Which of the following does the nurse recognize as a reassuring fetal heart rate (FHR) pattern? Spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds Late decelerations that occur with over 50% of contractions Repetitive (at least 3) uncomplicated variable decelerations Late decelerations with minimal variability

Correct response: Spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds Explanation: An increase of 15 bpm of the FHR for the duration of at least 15 seconds is a normal, reassuring FHR pattern. Late decelerations are periodic uniform changes in the FHR that are associated with uterine contractions. Multiple late decelerations may be a result of uteroplacental insufficiency or compromised uteroplacental perfusion requiring an intervention in attempts to enhance circulation and fetal oxygenation. Repetitive variable decelerations may be associated with umbilical cord compression and may require changes in maternal positioning to relieve the cord compression.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? Give the feedings at room temperature. Stop the feedings and check for residual volume. Place the client in semi-Fowler's position while feeding. Change the feeding container daily.

Correct response: Stop the feedings and check for residual volume. Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis? Hypotension Tachycardia Hot, dry skin Constricted pupils

Correct response: Tachycardia Explanation: Amphetamines, which are central nervous system stimulants, cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

The physician has placed a client who has suffered the loss of a child on a selective serotonin reuptake inhibitor (SSRI) for depression. The nurse is aware that the greatest risk for suicide would be during which time period? Ten to fourteen days after the initial medication regime is implemented Once the client is discharged home with family On the 1-year anniversary of the child's death When the nurse sees the client visiting with other clients on the nursing unit

Correct response: Ten to fourteen days after the initial medication regime is implemented Explanation: Ten to fourteen days is the normal response time for antidepressant medications to take effect and subsequent return of energy levels to perform the suicide act. There is no information about problems with the family that would precipitate suicide. The 1-year anniversary could be a stimulus, but a lower priority. Visiting with other clients is a positive interaction with elevation of mood.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? Tetany Hemorrhage Thyroid storm Laryngeal nerve damage

Correct response: Tetany Explanation: Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

A physician orders an antibiotic for a child, age 6, who has an upper respiratory tract infection. To avoid tooth discoloration, the nurse expects the physician to avoid prescribing which drug? Penicillin Erythromycin Tetracycline Amoxicillin

Correct response: Tetracycline Explanation: Tetracycline should be avoided in children younger than age 8 because it may cause enamel hypoplasia and permanent yellowish gray to brownish tooth discoloration. Penicillin, erythromycin, and amoxicillin don't discolor the teeth.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. The alveoli expand and increase the lung surface available for ventilation.

Correct response: The alveoli expand and increase the lung surface available for ventilation. Explanation: Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

A nurse administers the first dose of nadolol to a client with a blood pressure of 180/96. During an assessment, 4 hours later, which information indicates that the client needs immediate intervention? The client has wheezing throughout their lung fields. The client's heart rate has decreased from 88 to 76 beats/minute. The client's blood pressure (BP) is 142/90 mm Hg. The client has cool fingers and toes bilaterally.

Correct response: The client has wheezing throughout their lung fields. Explanation: Wheezing indicates the client is experiencing bronchospasms, which are a common adverse effect of a noncardioselective beta blocker. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the healthcare provider. The other symptoms are all expected effects of nadolol.

Which indicates that the client with diabetes insipidus understands how to manage care? The client will maintain normal fluid and electrolyte balance. The client will select a diabetic diet correctly. The client will state dietary restrictions. The client will exhibit serum glucose level within normal range.

Correct response: The client will maintain normal fluid and electrolyte balance. Explanation: Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus.

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and his immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? The nurse caring for this client is also caring for four other immunosuppressed clients on the medical floor. The nurse caring for this client is also caring for four clients receiving chemotherapy for cancer treatment on the oncology floor. The nurse caring for this client is also caring for two other immunosuppressed clients on the medical intensive care unit. The nurse is caring for this client on the intensive care unit.

Correct response: The nurse is caring for this client on the intensive care unit. Explanation: This client is critically ill; his diagnosis and immunosuppression place him at a high risk for infection. The most appropriate place for this client is in an intensive care unit, where the nurse can focus exclusively on his health promotion. This client shouldn't be on the oncology floor. This client requires close monitoring. The nurse caring for this client shouldn't also be caring for other clients who may require frequent interventions.

A child who was hospitalized for sickle cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises? The parent verbalizes the need to stay away from persons with known infections. The parent verbalizes appropriate dietary restrictions. The parent verbalizes the need to restrict fluid intake. The parent participates in an aerobic exercise program.

Correct response: The parent verbalizes the need to stay away from persons with known infections. Explanation: Preventing infections through proper hand washing and staying away from persons with known infections is an important measure in preventing sickle cell crises. Dietary restrictions aren't significant in preventing these crises. The client should maintain adequate hydration, not restrict fluid intake, and should avoid strenuous activity such as aerobics.

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions? To attempt to establish a trusting relationship To provide a structured environment for the client To instill hope in the client To provide time for completing nursing responsibilities

Correct response: To attempt to establish a trusting relationship Explanation: Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective. Although important, structuring the environment and instilling hope aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to plan the workload but isn't the major reason for such scheduling.

A child's parents state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the parents? Safety latches on kitchen cabinets Toy chest in front of a second-story, locked window Pot handles turned toward the back of the stove Hot water heater temperature set at 120° F (48.9° C) or below

Correct response: Toy chest in front of a second-story, locked window Explanation: A toy chest in front of a second-story locked window displays misunderstanding because toddlers are able to climb on low furniture and open windows that may not always be locked, especially in the summer. In such situations, the child could fall out of the window. Keeping child safety latches on kitchen cabinets, turning pot handles toward the back of the stove, and setting the hot water heater at a nonscalding temperature are all safeguards against toddler injury. These safeguards demonstrate full understanding of a toddler's developmental abilities.

Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first? Notify the health care provider (HCP). Turn off the oxytocin infusion. Turn the client to her left side. Increase the maintenance IV fluids.

Correct response: Turn off the oxytocin infusion. Explanation: The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.

Lower back pain is a common concern among pregnant clients. Which comfort measure should a nurse include in her teaching plan for a pregnant client? Wear high-heeled shoes. Use an ergonomically correct desk chair. Avoid tilting the pelvis forward. Bend at the waist, not at the knees.

Correct response: Use an ergonomically correct desk chair. Explanation: The nurse should instruct the client to use an ergonomically correct desk chair to help alleviate lower back pain. Wearing high heels promotes imbalance and falls. The nurse should not instruct the client to avoid tilting the pelvis forward, because standing with her neck and shoulders straight and pelvis tilted forward alleviates stress caused by excess uterine weight. Bending and lifting at the knees (not at the waist) alleviates strain on lower back muscles.

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

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

A physician orders penicillin G, 300,000 units I.M., for an 18-month-old child. Where should the nurse administer this injection? Deltoid muscle Vastus lateralis muscle Dorsogluteal muscle Ventrogluteal muscle

Correct response: Vastus lateralis muscle Explanation: For a child *younger than age 3*, the thigh (vastus lateralis muscle) is the best site for I.M. injections because it has few major nerves and blood vessels. The deltoid, dorsogluteal, and ventrogluteal sites aren't recommended for a child younger than age 3 because of the lack of muscle development and the risk of nerve injury during injection. Before the dorsogluteal or ventrogluteal sites can be used safely, the child should have been walking for at least 1 year to ensure sufficient muscle development.

The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor? When the neonate has been born When the client is fully dilated and effaced When the placenta has been birthed When the client is 2 hours postpartum

Correct response: When the placenta has been birthed Explanation: The third stage of labor is indicated by the birth of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.

When preparing to give a child with insulin-dependent diabetes his dose of regular insulin and isophane insulin suspension, which of the following actions is most appropriate? Taking the premixed insulin out of the refrigerator, then withdrawing the amount into one syringe. Using two syringes, one for each type of insulin, and giving two injections. Withdrawing the isophane insulin suspension first, then withdrawing the regular insulin into one syringe. Withdrawing the regular insulin first, then withdrawing the isophane insulin suspension into one syringe.

Correct response: Withdrawing the regular insulin first, then withdrawing the isophane insulin suspension into one syringe. Explanation: Using only one syringe is recommended for the child taking regular insulin along with an intermediate- or long-acting insulin. Additionally, insulin types, such as protamine zinc, globin zinc, and isophane insulin suspension, contain an additional modifying protein that slows absorption. Therefore, a vial of insulin that does not contain the protein (such as, regular insulin) should never be contaminated with insulin that does have the added protein. Premixing is rarely recommended because isophane insulin suspension does not remain stable for extended periods when mixed with regular insulin. Using two syringes is not recommended because the insulin types can be mixed. Also, using two syringes is more expensive. Insulin types, such as protamine zinc, globin zinc, and isophane insulin suspension, contain an additional modifying protein that slows absorption. A vial of insulin that does not contain the protein (i.e., regular insulin) should never be contaminated with insulin that does have the added protein.

A child admitted to the pediatric ward experiences an adverse reaction to a medication. After reviewing the medical record and speaking with the parents, the nurse identifies that they recently adopted this child from overseas, and there is no available medical history on the child. The nurse's priority action should be to: recommend contacting the adoption agency for the child's birth family medical history. assess and monitor the child, document the adverse event, and reassure the parents of the child's safety. contact the physician to request an order for a full allergy panel workup as soon as possible. instruct the parents that their child will be protected and placed in full isolation precautions.

Correct response: assess and monitor the child, document the adverse event, and reassure the parents of the child's safety. Explanation: The nurse's priority remains the safety and care of the child (including documentation), as well as supporting and educating the parents. Recommending that the adoption agency be contacted is a good long-term strategy, but likely would be unproductive on an emergency basis as it was an international adoption. An allergy workup may be helpful on a long-term basis, but the nurse must recognize that allergies can develop at any time in the course of disease or treatment protocol. It is inappropriate to place this child in full isolation precautions based on the available information.

A charge nurse is making assignments for a team that includes two registered nurses (RNs) and one unlicensed assistive personnel (UAP). One client requires a nurse to perform several complex procedures. The charge nurse should: assign each complex procedure to a different RN. assign the same number of clients to each RN, but with lower acuity. assign fewer clients to the RN managing this client's care. assign additional UAP to assist the RN.

Correct response: assign fewer clients to the RN managing this client's care. Explanation: The charge nurse assigns fewer clients to the RN who will be taking care of the client with high-acuity needs. Even though the RN would be assigned clients with lower acuity in addition to the client with high acuity, the RN will be planning care for more clients. Dividing the care for the high acuity client among several RNs increases the risk of error. The UAP will not be able to perform the complex procedures required for the high-acuity client.

A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that he has pedophilia. The nurse should: be aware of personal opinions and views. recognize that because the client is depressed, the client will not be able to discuss the pedophilia. ensure that the client is never alone with other clients on the unit. refer the client to group therapy.

Correct response: be aware of personal opinions and views. Explanation: The nurse must be aware of personal opinions and views when caring for clients with psychosexual disorders. The care plan for the client will be developed to manage both the depression and the pedophilia. It is not necessary to restrict the client's interactions with others on this adult mental health unit. The health care provider (HCP) will determine the type of therapy that will be most appropriate for this client.

The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk? blond, blue-eyed, fair-skinned child with eczema African descent, dark-eyed child with asthma child with dark complexion who is overweight and has labile personalities child with dark complexion who is overweight and has labile personalities

Correct response: blond, blue-eyed, fair-skinned child with eczema Explanation: Infants with PKU are usually blond, blue-eyed, and fair, and often have eczema. The other physical assessment findings are not typically found in children with PKU. Phenylketonuria (PKU) is an inborn error of metabolism that results in decreased metabolism of the amino acid phenylalanine

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

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

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse would expect that the client has: decreased breath sounds on the affected side. normal bronchial breath sounds. hyperresonance on percussion. wheezing on auscultation.

Correct response: decreased breath sounds on the affected side. Explanation: A pleural effusion is a collection of fluid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fluid, percussion would elicit dullness, not hyperresonance. The nurse should not expect to hear wheezing on auscultation.

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should first: elevate the stump. reinforce the dressing. call the surgeon. draw a mark around the site.

Correct response: draw a mark around the site. Explanation: The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.

A client newly diagnosed with deep vein thrombosis (DVT) of the left lower left extremity is on bed rest. The nurse should instruct the unlicensed assistive personnel (UAP) providing routine morning care for the client to: check that the legs are in a low, dependent position. ensure that the lower extremity is elevated. massage the leg and foot with lotion. place one or two pillows under the client's left knee.

Correct response: ensure that the lower extremity is elevated. Explanation: DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus.

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: ensuring that the suspected child abuse is reported to local authorities. contacting the infant's next of kin to begin discharge planning. reporting her suspicions to the hospital's chief of pediatric services. contacting the local children's protective service office with an anonymous tip.

Correct response: ensuring that the suspected child abuse is reported to local authorities. Explanation: Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to his next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.

The client with a peptic ulcer is prescribed antibiotics and bismuth salts. The nurse explains that this combination of medications will: prepare his bowel for surgery. eradicate the Helicobacter pylori bacteria. prevent future ulcers from forming. prevent bleeding from the ulcer.

Correct response: eradicate the Helicobacter pylori bacteria. Explanation: H. pylori is present in 70% of clients with peptic ulcers. Bacteriostatic or bacteriocidal antibiotics are given to eradicate the bacteria from the gastric mucosa. Bismuth salts suppress the H. pylori bacteria and help to heal the mucosa. Although sometimes indicated, surgery for peptic ulcer is much less common now that the role of H. pylori in the development of gastric ulcers is understood. The bowel preparation for gastric surgery does not include bismuth salts. While treatment for H. pylori drastically reduces the recurrence rate, 10% of clients treated for H. pylori will have a recurrence of peptic ulcer disease. While effective treatment will eliminate the possibility of complications, antibiotics and bismuth salts will not directly prevent bleeding.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? every 5 minutes every 10 minutes every 15 minutes every 20 minutes

Correct response: every 15 minutes Explanation: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should: explore the nurse's own feelings about the issues of anencephaly and organ donation. contact the client's minister to discuss the client's options related to the pregnancy. advise the client that the prolonged neonatal death will be very painful for her. ask the client if her family agrees with her decision.

Correct response: explore the nurse's own feelings about the issues of anencephaly and organ donation. Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some of these infants live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse should explore his or her feelings about the issue of anencephaly and organ donation. The nurse should not make judgments about the client's position, nor should the nurse try to persuade the client to terminate the pregnancy. Contacting the client's minister to explore the client's options is not appropriate. As a devout Baptist, the client probably has already discussed the matter with her minister. Telling the client that the neonatal death will be prolonged and painful to her is not helpful. Death may occur very soon after birth. Asking the client about her family's opinion does not help the support the client's decision.

A nurse feels that a 5-year-old boy in her care is showing signs and symptoms of diabetes mellitus. The nurse should: gather supporting evidence and contact the physician with her concerns. ask the dietitian to talk with the child and his parents about a diabetic diet. ask the laboratory to perform a random glucose test. monitor the child's activity for 24 hours.

Correct response: gather supporting evidence and contact the physician with her concerns. Explanation: If a nurse suspects a diagnosis, she must evaluate the situation further and collect more data. Then she should present her findings to the physician. It isn't appropriate for the nurse to wait 24 hours before addressing the possible diabetes. It would be premature for the nurse to contact the dietitian about a diabetic diet, and a nurse doesn't have authority to order a random glucose test.

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief? lithotomy right lateral hands and knees tailor sitting

Correct response: hands and knees Explanation: Placing the client in the hands and knees position pulls the fetal head away from the sacral promontory (relieving pain) and facilitates rotation of the fetus to the anterior position. Lithotomy is the position preferred by some health care providers (HCP) for delivery but does not facilitate rotation. The right lateral position will perpetuate the ROP position. Tailor sitting facilitates descent in OA positions.

A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid: has a more predictable onset of action. produces fewer anticholinergic effects. produces fewer drug interactions. has a longer duration of action.

Correct response: has a more predictable onset of action. Explanation: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which sexually transmitted infection? gonorrhea Chlamydia trachomatis infection syphilis herpes genitalis

Correct response: herpes genitalis Explanation: The client is reporting symptoms typically associated with herpes genitalis. Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. C. trachomatis infection in women is commonly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre.

Which diet would be most appropriate for the client with ulcerative colitis? high-calorie, low-protein high-protein, low-residue low-fat, high-fiber low-sodium, high-carbohydrate

Correct response: high-protein, low-residue Explanation: Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

When teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs: in the uterus. when the ovum is released. near the fimbriated end. in the first third of the fallopian tube.

Correct response: in the first third of the fallopian tube. Explanation: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.

The nurse should teach the client with hepatitis A to: limit caloric intake and reduce weight. increase carbohydrates and protein in the diet. avoid contact with others and sleep in a separate room. intensify routine exercise and increase strength.

Correct response: increase carbohydrates and protein in the diet. Explanation: Low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest obtained to promote recovery. Social isolation should be avoided, and education on preventing transmission should be provided; the client does not need to sleep in a separate room.

Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness? living each day as it comes as fully as possible reliving the pleasant memories of days gone by expecting the worst and being grateful when it does not happen planning ahead for the remaining good times that will be spent together

Correct response: living each day as it comes as fully as possible Explanation: When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will: regain any weight lost within 4 weeks of the surgical procedure. eat three full meals a day without experiencing gastric complications. learn to self-administer enteral feedings every 4 hours. maintain adequate nutrition through oral or parenteral feedings.

Correct response: maintain adequate nutrition through oral or parenteral feedings. Explanation: An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently. It is not realistic to expect the client to regain weight loss within 4 weeks of surgery. After surgery, it is recommended that the client eat six small meals a day rather than three full meals to decrease symptoms of dumping syndrome. Enteral feedings are not part of the expected outcome for gastric surgery.

Which nursing intervention is most important in preventing septic shock? administering IV fluid replacement therapy as ordered obtaining vital signs every 4 hours for all clients monitoring red blood cell counts for elevation maintaining asepsis of indwelling urinary catheters

Correct response: maintaining asepsis of indwelling urinary catheters Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

The parent tells the nurse that an 8-year-old child is continually telling jokes and riddles to the point of driving the other family members crazy. The nurse should explain this behavior is a sign of: inadequate parental attention. mastery of language ambiguities. inappropriate peer influence. excessive television watching

Correct response: mastery of language ambiguities. Explanation: School-age children delight in riddles and jokes. Mastery of the ambiguities of language and of sentence structure allows the school-age child to manipulate words, and telling riddles and jokes is a way of practicing this skill. Children who suffer from inadequate attention from parents tend to demonstrate abnormal behavior. Peer influence is less important to school-age children, and while the child may learn the joke from a friend, he is telling the joke to master language. Watching television does not influence the extent of joke telling.

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should: use sterile technique when providing catheter care. ensure that clients who are incontinent have indwelling urinary catheters. minimize urinary catheter use and duration of use in all clients. clean the periurethral area with antiseptics.

Correct response: minimize urinary catheter use and duration of use in all clients. Explanation: Minimizing urinary catheter use and duration of use in all clients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and clients with impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of urinary catheters for clients who are incontinent; a bladder training program and frequent use of the toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse should not clean the periurethral area with antiseptics; cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after insertion or any manipulation of the catheter device or site is sufficient.

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important? monitoring intake and output obtaining daily weights monitoring the client for indications of constipation obtaining stool samples for hemoccult testing

Correct response: monitoring intake and output Explanation: Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

A nurse is teaching an 8-year-old with diabetes and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that when the child is ill they will provide: more calories. more insulin. less insulin. less protein and fat.

Correct response: more insulin. Explanation: The child needs more insulin during an illness, because the cells become more insulin resistant during illness and need more insulin to achieve a normal blood glucose level. Glucose levels rise with illness; therefore, more food calories are not needed. During an acute illness, simple carbohydrates and fluids are usually tolerated best.

To ensure safety for a hospitalized blind client, the nurse should: require that the client has a sitter for each shift. require that the client stays in bed until the nurse can assist. orient the client to the room environment. keep the side rails up when the client is alone.

Correct response: orient the client to the room environment. Explanation: The priority goal of care for a client who is blind is safety and preventing injury. The initial action is to orient the client to a new environment. Taking time to identify the objects and where they are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at all times or for the client to stay in bed until the nurse can assist. Using side rails creates unnecessary barriers and may be a safety hazard.

A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates: absence of nausea and vomiting. passage of mucus from the rectum. passage of flatus and feces from the colostomy. absence of stomach drainage for 24 hours.

Correct response: passage of flatus and feces from the colostomy. Explanation: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Neither absence of stomach drainage nor absence of nausea and vomiting is a criterion for judging whether gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery.

When assessing the development of a 15-month-old child with cerebral palsy, whichmilestone should the nurse expect a toddler of this age to have achieved? walking up steps using a spoon copying a circle putting a block in cup

Correct response: putting a block in cup Explanation: Delay in achieving developmental milestones is a characteristic of children with cerebral palsy. Ninety percent of typically developing 15-month-old children can put a block in a cup. Walking up steps typically is accomplished at 18 to 24 months. A child usually is able to use a spoon at 18 months. The ability to copy a circle is achieved at approximately 3 to 4 years of age.

A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fine except for this irrational belief that we will remarry." When collaborating with the health care provider (HCP) about a plan of care, which intervention would be most effective for the client at this time? a prescription for olanzapine 10 mg daily a joint session with the client and his ex-wife a prescription for fluoxetine 20 mg every morning referral to an outpatient therapist

Correct response: referral to an outpatient therapist Explanation: Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated.

A nurse is giving instructions to a client with a new colostomy. The client states, "I am so tired today; I just cannot think." The nurse should: reschedule the appointment at a time when the client is rested. give the client a written instruction sheet instead of verbal teaching. ask the client to concentrate because the instructions are important. give the teaching session to the spouse instead of the client.

Correct response: reschedule the appointment at a time when the client is rested. Explanation: The client's readiness to learn is compromised by fatigue and lack of concentration. The teaching session should be rescheduled to a better time for improved learning readiness. Written instructions or involving the spouse can supplement verbal instructions but cannot replace teaching the client directly.

The nurse uses Montgomery straps primarily so the client is free from: falls. bruises. skin breakdown. wandering.

Correct response: skin breakdown. Explanation: The nurse uses Montgomery straps primarily to avoid the removal of long-term abdominal dressing tape and ultimate skin breakdown.

A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used: to permit her mother to seek unconventional treatments. when making decisions about her care. alone and not in combination with other defense mechanisms. to allow her mother to continue in her role as a mother.

Correct response: to allow her mother to continue in her role as a mother. Explanation: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptance of the illness and its treatment and denial of the actual or potential seriousness of the disease. This may allow the client more psychological freedom to maintain her current roles in the family and elsewhere. Denial can be harmful if the client ignores standard medical therapies in favor of unconventional treatments. Denial is not helpful when it interferes with a client's willingness to seek treatment or make decisions about care. Using any one defense mechanism exclusively usually reflects maladaptive coping. Other defense mechanisms that may be used include regression, humor, and sublimation.

A nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the woman to: wait 1 month before trying to become pregnant again. make an appointment for follow-up human chorionic gonadotropin (hCG) level monitoring at the end of 1 year. discuss options for sterilization with the physician. use birth control for at least 1 year.

Correct response: use birth control for at least 1 year. Explanation: After experiencing a hydatidiform mole, the client should be counseled to use a reliable method of birth control for at least 1 year. Because of the risk of choriocarcinoma, her hCG levels need to be monitored monthly for 1 to 2 years. If hCG levels remain low, a woman may try to become pregnant after 1 year. The risk of recurrence of a hydatidiform mole is low. Sterilization isn't necessary after a hydatidiform mole.

A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to: adhere to a low-cholesterol diet. supplement the diet with pyridoxine (vitamin B6). get extra rest. avoid excessive sun exposure.

INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies.

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? Monitoring his temperature every 4 hours Increasing fluid intake Covering the client with a light blanket Providing a low-calorie diet

Providing a low-calorie diet Explanation: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever.

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? level of consciousness blood pressure cognitive function contraction pattern

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? You Selected: level of consciousness Correct response: blood pressure Explanation: Administration of an epidural anesthetic can result in a hypotensive effect on maternal blood pressure. Therefore, the priority assessment is the mother's blood pressure. Ephedrine or wedging the client to a position to keep pressure off the vena cava, such as on the left side, can be used to elevate maternal blood pressure should it drop too low. Epidural anesthesia has no effect on the level of consciousness or the client's cognitive function. Although the client's contraction pattern may decrease in frequency after administration of the anesthesia, the priority assessment is the client's blood pressure. After blood pressure is maintained, contractions can be assessed.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? a. Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. b. Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. c. Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. d. Ask the assistant manager to develop a plan for the review and revision of client-education materials.

b. Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Explanation: Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

When talking with 10-year-old children about death, the nurse should incorporate which guidelines? Select all that apply. a. Logical explanations are not appropriate. b. The children will be curious about the physical aspects of death. c. The children will know that death is inevitable and irreversible. d. Attitudes of the adults in their lives will influence the children. e. Teaching about death and dying should not start before age 11 years. f. Telling children that death is the same as going to sleep as a way of relieving fear is appropriate.

b. The children will be curious about the physical aspects of death. c. The children will know that death is inevitable and irreversible. d. Attitudes of the adults in their lives will influence the children. By age 10 years, most children know that death is universal, inevitable, and irreversible. School-age children are curious about the physical aspects of death and may wonder what happens to the body. Their cognitive abilities are advanced and they respond well to logical explanations. They should be encouraged to ask questions. The adults in their environment influence their attitudes toward death. Adults should be encouraged to include children in the family rituals and should be prepared to answer questions that might seem shocking. Teaching about death should begin early in childhood. Comparing death to sleep can be frightening for children and cause them to fear falling asleep.

A nurse is reviewing the health care provider's orders for a client admitted with systemic lupus erythematosus (SLE). Which medication would the nurse expect to find in this client's plan of care? Morphine Ketoconazole Hydroxychloroquine Dimenhydrinate

Hydroxychloroquine Explanation: Fatigue, photosensitivity and a "butterfly" rash on the face are all signs and symptoms of SLE. Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Pharmacological treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and dimenhydrinate is an antiemetic.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? Cool, clammy skin Jugular vein distention Increased urine osmolarity Decreased serum sodium level

Correct response: Increased urine osmolarity Explanation: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

Correct response: Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Tetanic contractions Jugular vein distention Weight loss Polyuria

Correct response: Jugular vein distention Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

The nurse is performing a vaginal examination on a client in labor. The nurse finds the fetal presenting part 1 cm above the ischial spines. The nurse should chart the station as: -1 station. +1 station. engaged. floating.

Correct response: -1 station. Explanation: If presenting part is above the ischial spines 1 cm, the station is -1. If the presenting part is 1 cm below the ischial spines, the station is +1. Engaged and floating are not descriptive of station. Remediation:

A nurse is reviewing orders for a client having an acute asthma attack. Which of the following medications should the nurse administer? Albuterol 2.5 mg per nebulizer Methylprednisolone 60 mg IV Salmeterol 50 μg per dry-powder inhaler Triamcinolone two puffs per metered-dose inhaler

Correct response: Albuterol 2.5 mg per nebulizer Explanation: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications are used for long-term control of asthma and are not considered "rescue" inhalers since they are not immediate acting bronchodilators.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? Encourage the client to close his eyes. Alternatively patch one eye every 2 hours. Turn out the lights in the room. Instill artificial tears.

Correct response: Alternatively patch one eye every 2 hours. Explanation: Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? Wash the circumcised penis with warm water Change the diaper as needed Keep a bandage on the site for 24 to 48 hours Apply petroleum jelly to the site for 24 to 48 hours

Correct response: Apply petroleum jelly to the site for 24 to 48 hours Explanation: Petroleum jelly should be applied to the site for the first 24 to 48 hours to prevent the skin edges from sticking to the diaper. A gauze or other type of bandage may or may not be used. Washing the area with warm water is indicated, but is not part of the initial care.

Before a routine checkup, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? Measure the head circumference. Auscultate the heart and lungs. Elicit the pupillary reaction. Weigh the child.

Correct response: Auscultate the heart and lungs. Explanation: The nurse should first ausculate the heart and lungs because this assessment rarely distresses an infant. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing him may cause distress, making the rest of the examination more difficult.

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

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

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem? Inform the nurse supervisor right away. Correct the problem and submit a written report. Speak to the coworker when she returns to the unit. Ask for a meeting with the coworker and a manager.

Correct response: Speak to the coworker when she returns to the unit. Explanation: When a nurse discovers substandard practice by another nurse, it is always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issue can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

A nurse should expect to administer which medication to a client with gout? Aspirin Furosemide Colchicine Calcium gluconate

Correct response: Colchicine Explanation: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout.

A 4-year-old child continues to come to the nurses' station after being told children are not allowed there. What behavior is the child exhibiting? attention-seeking behavior aggressive behavior resistive behavior exaggerated stress behavior

Correct response: attention-seeking behavior Explanation: The child wants attention from the nurse, even if the behavior is met by a negative response. Aggression, resistance against authority, and exaggerated stress are behaviors that can be associated with a 4-year-old. However, coming to the nurses' station after being told not to do so is not an example of these behaviors.

A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should: apply suction to the NG tube every hour. clamp the NG tube if the client complains of nausea. irrigate the NG tube gently with normal saline solution if ordered. reposition the NG tube if pulled out.

Correct response: irrigate the NG tube gently with normal saline solution if ordered. Explanation: The nurse can gently irrigate the tube if ordered, but must be careful not to reposition it. Repositioning can cause bleeding. The nurse should apply suction continuously — not every hour. The nurse shouldn't clamp the NG tube postoperatively because secretions and gas will accumulate, stressing the suture line.

The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to prevent: electrolyte imbalances. nausea or vomiting. excretion of excessive fluids accumulated during the night. sleep disturbances during the night.

Correct response: sleep disturbances during the night. Explanation: When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.

A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about: acetaminophen. dopamine. tamoxifen. progesterone.

Correct response: tamoxifen. Explanation: Tamoxifen is an estrogen blocker used to treat premenopausal and postmenopausal breast cancer and to prevent breast cancer in certain women who are at high risk. Acetaminophen is a nonopioid analgesic antipyretic. Dopamine is a vasoconstrictor used to treat hypotension. Progesterone is a hormone used to treat amenorrhea or dysfunctional uterine bleeding.

A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for: footdrop. knee swelling and pain. tingling in the arm. absence of the Achilles reflex.

Correct response: tingling in the arm. Explanation: A client who had a left thoracoscopy is placed in the lateral position, in which the most common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a brachial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery.

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

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

A child has been prescribed a 3-day course of treatment with gentamicin sulfate while recovering from surgery. Which assessment of the child causes the nurse to be the most concerned? A low calcium level Decreased urine output Joint discomfort Visual disturbances

Decreased urine output Explanation: Gentamicin sulfate is an antibiotic that can cause ototoxicity and nephrotoxicity. Therefore, a decrease in urine output would be concerning. None of the other options would be of concern as a side effect of gentamicin.

Which nursing action is most beneficial to prevent fungal infections in hospitalized clients? Keep the client's skin moisturized Bathe the client daily Dry all skin folds thoroughly Ensure air movement with a fan

Dry all skin folds thoroughly Explanation: Fungus spreads in warm, moist environments. The nurse must keep all skin folds on the warm body dry. Moisturized is needed for dry skin but does not prevent fungal infections. Bathing is appropriate but drying is key. Environmental air movement is not necessarily helpful.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem? Inform the nurse supervisor right away. Correct the problem and submit a written report. Speak to the coworker when she returns to the unit. Ask for a meeting with the coworker and a manager.

Speak to the coworker when she returns to the unit. Explanation: When a nurse discovers substandard practice by another nurse, it is always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issue can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: increasing fluid intake to prevent dehydration. wearing an appliance pouch only at bedtime. consuming a low-protein, high-fiber diet. taking only enteric-coated medications.

increasing fluid intake to prevent dehydration. Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

A suppository must be ___________ before insertion. Because suppositories melt at ______________, they usually require refrigeration until administration.

lubricated body temp

what weird thing does Diphenhydramine do?

provides rapid relief for dystonia (rapid muscle contractions/sustained contractions) (ie in parkinsons)

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? Assessment of client restraint location in relation to mental status Evaluation of client response to restraint type Completion of range of motion on limbs restrained Release of restraints as client symptoms improve

Any client assessment and subsequent decision making/judgment is in the scope of practice of the nurse. The unlicensed healthcare worker (UHW)/nursing assistant (NA) is able to complete the task of range of motion.

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

a. Provide brochures in the client's native language. d. Arrange for an interpreter for her appointments. f. Review dietary intake and discuss nutrition.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? every 5 minutes every 10 minutes every 15 minutes every 20 minutes

q15m

Which question has been added to nursing admission assessment to screen for the Zika virus? Have you recently traveled to Japan? Have you recently traveled to Africa? Have you recently traveled to Canada? Have you recently traveled to South America?

Correct response: Have you recently traveled to South America? Explanation: Central and South America are areas experiencing the transmission of the Zika virus.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? Increase calories. Restrict sodium. Restrict potassium. Reduce fat to 10%.

Correct response: Restrict sodium. Explanation: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

Sudoriferous glands secrete which type of substance? Sweat Oil Hormones Cerumen

Correct response: Sweat Explanation: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.

The mother of an infant with flat feet asks the nurse what she can do about the problem. Which response from the nurse is the most appropriate? "Infants have a fat pad below the arch, making it look like flat feet." "Nightly exercises will help make the arches supple." "Flat feet cause other orthopedic problems in infants." "Corrective shoes will strengthen the arches of the feet."

"Infants have a fat pad below the arch, making it look like flat feet." Explanation: Infants have a fat pad below the arch, giving the appearance of flat feet. Exercises will not correct flat feet. Flat feet cause no other orthopedic problems in infants. Corrective shoes will have no effect on strengthening the arches of the child's feet.

A hospital uses the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? "Client reporting abdominal pain rated at 8/10." "Client is guarding her abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "2 mg hydromorphone PO administered with good effect."

Correct response: "Client reporting abdominal pain rated at 8/10." Explanation: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a report of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: "Does your child's ear hurt?" "Does your child have any hearing problems?" "Does your child tug at either ear?" "Does anyone in your family have hearing problems?"

Correct response: "Does your child tug at either ear?" Explanation: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.

After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which statement? "A total weight gain of approximately 20 lb (9 kg) is recommended." "A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal." "A weight gain of about 12 lb (5.5 kg) every trimester is recommended." "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

Correct response: "Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average." Explanation: The National Academy of Sciences Institute of Medicine and Health Canada recommend that women gain 25 to 35 lb (11.5 to 14.5 kg) during pregnancy. The pattern of weight gain is as important as the total amount of weight gained. Underweight women and women carrying twins should have a greater weight gain. Typically, women should gain 3.5 lb (1.6 kg) during the first trimester and then 1 lb (0.45 kg)/week during the remainder of the pregnancy (24 weeks) for a total of about 27 to 28 lb (12.2 to 12.7 kg). A weight gain of only 6.6 lb (3 kg) in the second and third trimesters is not normal because the client should be gaining about 1 lb (0.45 kg)/week, or 12 lb (5.4 kg) during the second and third trimesters. Gaining 12 lb (5.4 kg) during each trimester would total 36 lb (16.2 kg), which is slightly more than the recommended weight gain. In addition, nausea and vomiting during the first trimester can contribute to a lack of appetite and smaller weight gain during this trimester.

Parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate? "Children of that age view death as temporary and reversible, which makes it hard to explain." "Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth." "At this developmental stage, children are afraid of death, so it's best not to discuss it with them." "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."

Correct response: "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it." Explanation: By age 9 or 10, most children have an adult concept of death. Therefore, caregivers should discuss death with them in terms consistent with their developmental stage. In addition, school-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. While school-age children may fantasize about the unknown aspects of death, these fantasies may actually increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of her car and beginning to approach the client's building, a group of men begin following and jeering at her. Which of the following is the nurse's best response to this situation? Leave the area in her car, provided she can get to it safely. Perform the home visit and ensure that the group is gone before she leaves. Confront the group of men in an assertive but non-aggressive manner. Call out to attract attention from bystanders.

Leave the area in her car, provided she can get to it safely. Explanation: The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove herself from the situation, provided this can be achieved without incurring further risk.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when the client says: "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm clear when my chest X-ray is negative after one month of medication." "I'm contagious as long as I have night sweats." "I'll stop being contagious when I have a negative acid-fast bacilli test."

"I'll stop being contagious when I have a negative acid-fast bacilli test." Explanation: A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when he/she shows clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test results for several days. The client will not have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they do not indicate whether the client is contagious.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? Cyanosis of the lips Bilateral crackles Productive cough Leg edema

Correct response: Leg edema Explanation: Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis (mouth), crackles, and a productive cough.

Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system? gastrointestinal renal pulmonary cardiac

The most common toxicities from NSAIDs are gastrointestinal disorders (nausea, epigastric pain, ulcers, bleeding, diarrhea, and constipation). Renal dysfunction, pulmonary complications, and cardiovascular complications from NSAIDs are much less common.

The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to: prevent hip flexion. decrease formation of sacral pressure ulcers. prevent dislocation of the prosthesis. increase peripheral circulation.

prevent dislocation of the prosthesis. Explanation: After a total hip replacement, it is important to maintain the hip in a state of abduction to prevent dislocation of the prosthesis. Use of an abduction pillow or splint will not prevent hip flexion or the formation of sacral pressure ulcers, nor will it increase peripheral circulation.

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

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