pass point 7

Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking? A breast-fed, 7-lb, 2-oz (3.2-kg) neonate who produces three stools and wets six diapers per day A breast-fed, 7-lb, 4-oz (3.3-kg) neonate who feeds on demand and averages ten feedings per day A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day fe A bottle-fed, 7-lb, 4-oz (3.3-kg) neonate who drinks 23 oz of formula per day over the course of eight feedings

A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day Explanation: A neonate with adequate nutrition voids six to eight times per day and has two or more bowel movements. A bottle-fed, 7-lb, 2-oz neonate who produces two stools and wets four diapers per day is at risk for imbalanced nutrition. Neonates need to be fed on demand, and breast-fed infants commonly feed every 2 hours. The 7-lb, 2-oz infant needs 17.5 to 21 oz of formula per day.

A nurse is caring for a client who required chest tube insertion for pneumothorax. To confirm pneumothorax resolution, what should the nurse anticipate the client will require? Monitoring of arterial oxygen saturation (SaO2) Arterial blood gas (ABG) studies Chest auscultation A chest X-ray

A chest X-ray Explanation: Chest X-ray reveals air or fluid in the pleural space and therefore displays the status of pneumothorax. SaO2 values may initially decrease with pneumothorax but typically return to normal within 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to pneumothorax. Chest auscultation determines overall lung status but doesn't clearly determine if the chest is sufficiently re-expanded.

A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings? A boggy uterus Normal involution A vaginal laceration A clotting problem

A vaginal laceration Explanation: A steady trickle of blood on the perineal pad of a client with a well-contracted uterus may indicate a vaginal, cervical, or perineal laceration. A boggy uterus would be palpable above the umbilicus and would be soft and poorly contracted. With normal involution, the perineal pad would show only lochia, not a trickle of blood. A clotting problem causes more than a steady trickle of blood and probably would have been identified earlier during labor.

At her follow-up examination, a client who's 6 weeks postpartum tells the nurse that she's exhausted and sore from breast-feeding and wants to formula-feed her baby. She also mentions that she feels like a failure and finds it increasingly difficult "just to get out of bed in the morning." Which intervention should the nurse attempt before notifying the physician? Examining the client's breasts to determine areas of breakdown, and discussing proper latch-on technique Praising the client for breast-feeding for 6 weeks and encouraging her to "hang-in there" as it takes time to toughen up the nipples Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system Acknowledging that breast-feeding can be difficult for some mothers, and reassuring the client that she's not a failure just because she wants to use formula

Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system Explanation: Mild depression affects more than 70% of clients postpartum but usually lasts no longer than 2 weeks. A client at 6 weeks who verbalizes feelings of failure, sadness, and extreme fatigue is exhibiting symptoms of postpartum depression. The nurse needs to establish priorities by addressing the client's depression before discussing breast-feeding.

When the physician prescribes an antibiotic to treat a child's ear infection, the nurse checks to see whether the ordered antibiotic could cause ototoxicity. Which of the following options belongs in this category? Cephalosporins Penicillins Aminoglycosides Carbapenems

Aminoglycosides Explanation: Aminoglycosides are ototoxic and may cause tinnitus, vertigo, and hearing loss. Cephalosporins, penicillins, and carbapenems (a new class of beta-lactam antibacterial agents) aren't associated with ototoxicity.

The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? Assessing the extremity for neurovascular integrity Keeping the client from sliding to the foot of the bed Keeping the ropes over the center of the pulley Ensuring that the weights hang free at all times

Assessing the extremity for neurovascular integrity Explanation: Although all measures are correct, assessing neurovascular integrity takes priority. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

The licensed practical nurse discovers a client with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he reports dizziness. Which medication would the registered nurse use to treat the client's bradycardia? Atropine Dobutamine Amiodarone Lidocaine

Atropine Explanation: I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom? Bleeding Difficulty swallowing Throat pain Difficulty talking

Bleeding Explanation: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days after the client's operation. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

When measuring the radial pulse of a client with known aortic insufficiency, the nurse detects a "water-hammer" or Corrigan's pulse. What are the characteristics of this pulse? Weak and feeble, with a slow upstroke and prolonged peak Alternating strong and weak beats Rapid upstroke with two systolic peaks Bounding, with a rapid rise and fall

Bounding, with a rapid rise and fall Explanation: A "water-hammer" pulse is bounding, with a rapid rise and fall. A weak, feeble pulse with a slow upstroke and prolonged peak is called pulsus tardus. A pulse with alternating weak and strong beats and a regular rhythm is termed pulsus alternans. A pulse with a rapid upstroke and two systolic peaks is called pulsus bisferiens.

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation? By allowing the eyelid to close during medication instillation By letting the medication drip onto the surface of the eye By positioning the neonate so that the head remains still By holding the neonate in the football position

By positioning the neonate so that the head remains still Explanation: After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn't secure the head.

Which method is most reliable for confirming a preschooler's identity before administering a medication? Check the name on the bed. Check the hospital identification bracelet. Ask the child his name. Ask the parents at the bedside.

Check the hospital identification bracelet. Explanation: The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers or preschoolers may admit to any name, and school-age children may deny their identities in an attempt to avoid the medication. Parents aren't always at the bedside, so they shouldn't be relied on for identification.

A client complains of periorbital aching, tearing, blurred vision, and photophobia in the right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. The nurse knows atropine sulfate belongs to which drug classification? Parasympathomimetic agent Sympatholytic agent Adrenergic blocker Cholinergic blocker

Cholinergic blocker Explanation: Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms? Coma, anxiety, confusion, headache, and cool, moist skin Kussmaul respirations, dry skin, hypotension, and bradycardia Polyuria, polydipsia, hypotension, and hypernatremia Polyuria, polydipsia, polyphagia, and weight loss

Coma, anxiety, confusion, headache, and cool, moist skin Explanation: Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

A nurse is caring for a client who is receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client? "Choose foods high in potassium." "Take potassium supplements each day." "Discontinue sodium restrictions." "Avoid salt substitutes."

"Avoid salt substitutes." Explanation: Because spironolactone is a potassium-sparing diuretic, the client should be taught to avoid salt substitutes because they have high potassium contents. Foods high in potassium and potassium supplements should also be avoided. Sodium restrictions should continue to reduce fluid volume overload.

The nurse is talking with the parent of a 3-year-old child who has congenital heart disease. The parent reports feeling concerns that the child does not seem to be maturing emotionally in a manner that is at the same rate as the two older children in the family. Which response by the nurse is most appropriate? "All children mature at different rates, so comparisons are not really fair." "Children who have chronic health issues may experience developmental delays." "The emotional immaturity you are seeing may just be your child's manner of acting out in response to being sick so much." "You will need to lower your expectations for your child's level of maturity."

"Children who have chronic health issues may experience developmental delays." Explanation: Chronic illnesses can impact a child's growth and development both emotionally and cognitively. The child with a cardiac disorder may experiences delays as a result of hypoxic episodes or because of repeated hospitalizations. Educating parents about these possibilities will be helpful in initiating the discussion about the child's level of maturity. Although children mature at different rates, this is not the best response. Children may act out in response to illness or other factors, but there is no information that supports this reason for the child's behavior. Encouraging parents to lower their expectations is not therapeutic.

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer? "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep." "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." "Crying at this age indicates hunger. Try feeding her when she cries."

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." Explanation: The nurse should advise the mother to continue to pick the infant up when she cries because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough for her to associate crying with getting attention, it would be difficult to spoil her at this age. Even if her diaper is dry, a gentle touch may be necessary until she falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry.

A nurse is caring for a client with thrush. Which instructions would be anticipated for treatment of this disorder? "Give the solution immediately after feedings." "Give the solution immediately before feedings." "Mix the solution with small amounts of the feeding." "Give half the solution before and half the solution after the feeding."

"Give the solution immediately after feedings." Explanation: Nystatin oral solution should be swabbed onto the mouth after feedings to allow for optimal contact with mucous membranes. Administering nystatin before meals or with meals does not allow the best contact with the mucous membranes.

A 2-year-old hospitalized child is HIV positive with severe thrush. The child's anxious grandparents are at the bedside, continually calling the nurses with various concerns. The staff speak disparagingly about them because they are tired of responding to the frequent call lights. When working with the unit's staff, which response by the nurse manager would be appropriate in creating a more optimal care environment for the child? "This situation will improve as you respond to the call light more promptly." "This couple is demanding, but we need to handle things in a professional manner." "It might be best to have the child transferred to a facility that's better staffed." "If we stop by the room before the light goes on, they may be less anxious."

"If we stop by the room before the light goes on, they may be less anxious." Explanation: Although the situation may improve with more prompt responses to the call light, stopping by the room before the light goes on addresses the needs of the family. This response encourages the staff to be proactive and compassionate and provide prompt nursing intervention. The staff should handle the situation more professionally, providing individualized care based on the needs of the family. Transferring the child to a better-staffed facility is not a therapeutic solution.

A nurse cares for a client diagnosed with osteoarthritis. To minimize injury to this client, what education should be reinforced? "Install safety devices in your home." "Wear shoes that promote comfort." "Ask for help when lifting objects." "Use protective devices when exercising."

"Install safety devices in your home." Explanation: Most accidents occur in the home, and safety devices are the most important element in minimizing injury. For a client diagnosed with osteoarthritis, shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or picking up objects; it is not necessary to ask for help with these actions. Protective devices are not usually necessary for the client to exercise.

The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the most accurate? "Clonic seizure activity is usually interpreted as falling." "It's not unusual to develop seizures after a head injury because of brain trauma." "Focal discharge in the brain may lead to absence seizures that go unnoticed." "The brain needs multiple stimuli before it manifests as a seizure."

"It's not unusual to develop seizures after a head injury because of brain trauma." Explanation: Stimuli from an earlier injury may eventually elicit seizure activity, a process known as kindling. Atonic seizures, not clonic seizures, are commonly accompanied by falling. Focal seizures are partial seizures; absence seizures are generalized seizures. Focal seizures don't lead to absence seizures. The epileptogenic focus consists of a group of hyperexcitable neurons responsible for initiating synchronous, high frequency discharges that lead to a seizure and don't need multiple stimuli.

Which statement made by the parent of a 16-month-old child with cystic fibrosis should alert a nurse to investigate further? "My child is not walking yet." "My child is saying a few words and short phrases." "My child doesn't interact with other 16-month-olds." "My child cries when I leave the room."

"My child is not walking yet." Explanation: A toddler should be walking by 15 months. At 10 months, an infant holds on to furniture while walking, walks with support at 11 months, and takes his first steps at 12 months. By 12 months, a child can say a few words, with more words and short phrases being added each month. A child at 16 months, the child engages in solitary play and has little interaction with other children. Separation anxiety is common in toddlers.

A nurse is reinforcing education for a client with a long leg cast on how to use crutches properly while descending a staircase. What step should the nurse inform the client to do first? "Both legs should be advanced first.". "Advance the unaffected leg and one crutch." "The affected leg should be advanced first." "Place the crutches on the first stair below you."

"Place the crutches on the first stair below you." Explanation: To walk down a flight of stairs, body weight is first transferred to the unaffected leg. Both crutches are then advanced to the stair below. Body weight is transferred to the crutches as the affected leg descends. The unaffected leg is then brought down to the next step so that both legs and crutches are all on the same step. The procedure is repeated for each step.

A nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, what should the nurse instruct the client to do? "Sneeze with your mouth open." "Blow your nose frequently." "Clean your operated ear with a cotton-tipped applicator twice per day." "Resume bending when you are no longer experiencing any ear pain."

"Sneeze with your mouth open." Explanation: If sneezing cannot be avoided, the client should sneeze with his mouth open to prevent air pressure changes in the middle ear, which can dislodge the prosthesis and graft. Blowing the nose and coughing should be avoided. Small objects, such as cotton-tipped applicators, should not be inserted into the ear. Straining during a bowel movement and bending should be avoided for at least 2 to 3 weeks, or as instructed by the primary care provider.

The nurse is caring for a client who reports of lower back pain. Which instructions should the nurse give the client to prevent back injury? "Bend over the object you are lifting." "Narrow the stance when lifting." "Push or pull an object using your arms." "Stand close to the object you are lifting."

"Stand close to the object you are lifting." Explanation: Standing close to an object when lifting moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using multiple muscle groups distributes the workload.

Which statement by a caregiver indicates that a 10 month old is at high risk for iron deficiency anemia? "The baby is sleeping through the night without a bottle." "The baby drinks about five 8-oz bottles of milk per day." "The baby likes egg yolk in his cereal." "The baby likes all vegetables except carrots."

"The baby drinks about five 8-oz bottles of milk per day." Explanation: The recommended intake of milk, which doesn't contain iron, is 24 oz per day; 40 oz per day exceeds the recommended allotment and may reduce iron intake from solid food sources, risking iron deficiency anemia. Sleeping through the night without a bottle is an anticipated behavior at this age. Egg yolk is a good source of iron and would minimize any risk factor related to nutritional anemia. Because only dark-green vegetables are good sources of iron, a dislike of carrots wouldn't be significant for this client.

A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be an appropriate response? "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 with a man who isn't even real."

"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 the client in a less threatening or more comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the false belief. The other options focus on the content of the delusion rather than the meaning, feeling, or intent that it provokes.

A client who is 9 days postpartum and breastfeeding her baby reports pain, redness, swelling of her left breast and is diagnosed with mastitis. The nurse is reviewing information with the client about how to care for her infected breast. Which information should the nurse most likely reinforce? "Wear a loose-fitting bra to avoid constricting the milk ducts." "Stop breastfeeding permanently." "Take antibiotics until the pain is relieved." "Use a warm, moist compress over the painful area."

"Use a warm, moist compress over the painful area." Explanation: A client with mastitis should use warm, moist compresses to reduce inflammation and edema of the infected breast tissue. She should wear a proper-fitting bra with good support; she should also breastfeed the baby or pump frequently to help empty the affected breast and ensure an adequate milk supply. Antibiotics are prescribed to treat mastitis and must be taken for the full course of therapy, not stopped when pain symptoms subside.

A client in the final stages of terminal cancer tells the nurse, "I wish I could just be allowed to die. I'm tired of fighting this illness. I've lived a good life. I only continue my chemotherapy and radiation treatments because my family wants me to." What is the nurse's best response? "Would you like to talk to a psychologist about your thoughts and feelings?" "Would you like to talk to your minister about the significance of death?" "Would you like to meet with your family and your health care provider about this matter?" "I know you are tired of fighting this illness, but death will come in due time."

"Would you like to meet with your family and your health care provider about this matter?" Explanation: The nurse has a moral and professional responsibility to advocate for clients who experience decreased independence, loss of freedom of action, and interference with their ability to make autonomous choices. Coordinating a meeting between the health care provider and family members may give the client an opportunity to express his or her wishes and promote awareness of his or her feelings as

A client is prescribed haloperidol. When reinforcing the teaching plan about the drug, which instruction would the nurse emphasize? "You should report feelings of restlessness or agitation at once." "You can take your herbal supplements safely with this drug." "Be aware that you'll feel increased energy taking this drug." "This drug will indirectly control essential hypertension."

"You should report feelings of restlessness or agitation at once." Explanation: Agitation and restlessness are adverse effects of haloperidol that can be treated with anticholinergic drugs. Using herbal supplements while taking haloperidol may interfere with the drug's effectiveness. Although the client may experience increased concentration and activity, these effects are due to a decrease in symptoms, not to the drug itself. Haloperidol isn't likely to cause essential hypertension.

A client comes to the emergency department reporting pain in the right leg. When obtaining his history, the nurse learns that the client was diagnosed with diabetes mellitus at age 12. The nurse knows that this disease predisposes the client to which musculoskeletal disorder? Degenerative joint disease Muscular dystrophy Scoliosis Paget's disease

Degenerative joint disease Explanation: Diabetes mellitus predisposes the client to degenerative joint disease. It isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

During a routine assessment, a pregnant client tells the nurse that she hasn't had a bowel movement for "close to a week." What should the nurse do to help this client? Suggest that the client take Milk of Magnesia when she returns home. Recommend that the client take castor oil before bedtime. Discuss the client's diet, focusing on her fiber and water intake. Ask the health care provider to prescribe a laxative for this client.

Discuss the client's diet, focusing on her fiber and water intake. Explanation: Many medications are not safe during pregnancy; therefore, the nurse should suggest that the client increase her consumption of water and fiber to facilitate a bowel movement.

The nurse is caring for a client with dementia who chokes easily. What nursing action would be appropriate when administering donepezil, orally dissolving tablets (ODT)? Swallow whole, followed by a glass of water. Dissolve on the tongue, followed by a glass of water. Do not take with water; dissolve in the cheeks of the mouth. Chew tablet, then drink a glass of fluid.

Dissolve on the tongue, followed by a glass of water. Explanation: ODT medication should dissolve on the tongue followed by drinking a glass of water. It should not be swallowed whole, chewed, or dissolved in the cheek of the mouth.

The licensed practical nurse (LPN) prepares a client's regularly scheduled prescribed medications. The client refuses to take them. Which action should the LPN take? Explain to the client about the need for the medications because the health care provider prescribed them. Tell the client that refusing to take the medications will worsen the current condition. Document in the client's medication administration record that the medications were refused. Explain to the client's family that the client refused to take the medications.

Document in the client's medication administration record that the medications were refused. Explanation: The client has the right to refuse medication. Therefore, the nurse should document in the medication administration record that (a) the medications were not given and (b) why the client refused them. The nurse should also inform the supervising registered nurse and health care provider that the client refused the medications. The nurse should review with the client the reason for the medication but cannot force the client to take them. Forcing a client to take medications is considered assault. Telling the client that the current condition will worsen without the medications is making a medical judgment, which is out of the scope of practice for an LPN. Informing the client's family breaches client confidentiality.

The health care provider requests four prescriptions for a client with diabetes who has an infected foot ulcer. Which prescription should the nurse complete first? Start levofloxacin 1-gram IV piggyback every 24 hours. Monitor blood glucose before meals and at bedtime. Draw a CBC, metabolic panel, and creatinine now. Perform a wet-to-dry dressing change every 8 hours.

Draw a CBC, metabolic panel, and creatinine now. Explanation: The nurse should draw the complete blood count and serum creatinine first before starting a fluoroquinolone, such as levofloxacin to determine the baseline hematologic, metabolic, and renal functioning. Adverse reactions reported in clients receiving fluoroquinolones include anemia, (hemolytic and aplastic), thrombocytopenia, leukopenia, agranulocytosis, pancytopenia and/or other hematologic abnormalities, interstitial nephritis, acute renal insufficiency or failure, and blood glucose disturbances. Wet-to-dry dressings are appropriate for a client with diabetes who has a foot ulcer, but this is not a priority. Blood glucose monitoring before meals and at bedtime is not an immediate priority, and a random glucose is included with the metabolic panel.

A baby born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation? Keeping him away from drafts Putting a blanket between him and cold surfaces Putting a cap on his head Drying him thoroughly after a bath

Drying him thoroughly after a bath Explanation: Babies lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss due to evaporation. Keeping a baby away from drafts prevents heat loss due to convection. Keeping a baby off a cold surface, such as a scale, prevents the loss of heat due to conduction. Placing a cap on the baby's head preserves heat and prevents heat loss due to radiation.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? Apply ice to the toes and foot. Contact the orthopedic surgeon. Elevate the foot of the bed. Utilize a traction sling to raise the extremity.

Elevate the foot of the bed. Explanation: To relieve edema of the toes, the nurse should raise the affected extremity above the heart level such as by elevating the foot of the bed. Contacting the orthopedic surgeon is not necessary at this time. Applying ice may be effective but raising the extremity will be more effective. Using traction is not indicated.

A client with a knee-to-toe cast applied informs the nurse that they are having severe itching in the ankle area and need something to scratch it with. What is the priority nursing action? Use a blower dryer on the heat application to relieve the itching. Give the client a sterile metal object to use for scratching. Encourage the client to avoid scratching, and confer with the health care provider if severe itching persists. Obtain a prescription for a sedative, such as diazepam, to prevent the client from scratching.

Encourage the client to avoid scratching, and confer with the health care provider if severe itching persists. Explanation: Clients should not scratch inside casts because of the risk of skin breakdown and potential damage to the cast. The nurse should consider notifying the health care provider if itching persists. The health care provider may prescribe an antihistamine, such as diphenhydramine, to relieve itching. Sedatives are not generally indicated for itching. A blow dryer on the heat setting could cause burns and increase itching due to vasodilation. Using it on the cool setting may be of some relief.

Which nursing intervention would be the priority when caring for a client with a dissociative disorder? Encouraging the client to participate in unit activities and meetings Questioning the client about the events triggering the dissociative disorder Allowing the client to remain in the client's room anytime the client is experiencing feelings of dissociation Encouraging the client to form friendships with other clients in his therapy groups to decrease his feelings of isolation

Encouraging the client to participate in unit activities and meetings Explanation: Individuals with certain dissociative disorders feel detached from their environment and can experience impaired social functioning. Attending unit activities and meetings helps decrease the client's sense of isolation. Often, the client can't recall the events that triggered the dissociative disorder, so the client would need to be isolated from others only if the client couldn't interact appropriately. A client with a dissociative disorder has typically had few healthy relationships. Forming friendships with others in therapy could result in the client establishing unhealthy relationships.

A 3-year-old child has had surgery to remove a Wilms tumor. Which action should the nurse take first when the parent asks for pain medication for the child? Get the pain medication ready for administration. Gather data regarding the child's pain using a pain scale of 1 to 10. Gather data regarding the child's pain using a smiley face pain scale. Check for the last time pain medication was administered.

Gather data regarding the child's pain using a smiley face pain scale. Explanation: The first action by the nurse should be to gather data from the child regarding pain. A 3-year-old child is too young to use a pain scale from 1 to 10, but can easily use the smiley face pain scale. After gathering data regarding the child's pain, the nurse should then investigate the time the pain medication was last given and administer the medication accordingly.

An 18-month-old is admitted to the emergency department with a diagnosis of seizure. Upon evaluation, the child's vital signs are: temperature, 104° F (40° C); respiratory rate, 26 breaths/minute; pulse, 120 beats/minute; and blood pressure, 90/69 mm Hg. Which action should the nurse take first? Give a tepid sponge bath. Administer phenytoin. Obtain a finger-stick glucose level. Obtain a blood specimen to check electrolyte levels.

Give a tepid sponge bath. Explanation: The child's seizure was most likely caused by fever. Therefore, the nurse should try to lower the child's core body temperature by giving a tepid sponge bath. Phenytoin isn't prescribed for fever-related seizures. At this time, it isn't necessary to obtain a finger-stick glucose level or a blood specimen for electrolytes.

A client in the early stages of labor who is admitted to the labor and delivery unit is noted to have not recently bathed or changed her clothes. Which action should the nurse take to help this client? Wait for the client to request a shower. Allow the client to wear what she prefers, even if it's soiled. Help the client to undress and suggest a quick bath to freshen up. Assist the client into a clean hospital gown and offer her deodorant.

Help the client to undress and suggest a quick bath to freshen up. Explanation: The nurse should respectfully address the client's hygiene needs by helping the client to undress and offering her a quick bath. It's unsafe for the client to get into a shower at this point. Allowing the client to remain in soiled clothes may place the neonate at risk for infection. Giving the client a clean gown and offering her deodorant doesn't address the client's hygiene needs.

A client is receiving oxytocin to treat postpartum hemorrhage. The nurse recognizes which common adverse reactions may be associated with the medication? Abdominal cramps and diarrhea Hypertension and tachycardia Headache and facial flushing Blurred vision and dizziness

Hypertension and tachycardia Explanation: Oxytocin may cause hypertension and tachycardia. The nurse should monitor the client for these adverse effects. Abdominal cramps, diarrhea, headache, facial flushing, blurred vision, and dizziness aren't typically associated with oxytocin.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism? Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing Disturbed body image related to weight gain and edema Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess Explanation: In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis. Options 2 and 3 may be appropriate for a client with hypothyroidism, which slows the metabolic rate.

A nurse is caring for a client who is awaiting surgery for a hip fracture. Which nursing intervention has the highest priority when providing skin care for this client? Change the bed linens frequently for an incontinent client. Keep the skin clean and dry without using harsh soaps. Gently massage the skin around pressure areas. Rub moisturizing lotion over pressure areas.

Keep the skin clean and dry without using harsh soaps. Explanation: Keeping the skin clean is always the highest priority when providing skin care to a bedridden client. The other measures are also important, but the nurse should rub around, not directly over, pressure areas to avoid skin breakdown.

When a client with a halo vest is discharged from the hospital, which instruction should the nurse reinforce to the client and family? Don't use the wheelchair while the halo vest is in place. Clean the pin sites every other day especially when there is abscess. Keep the wrench that opens the vest attached to the client at all times. Perform range-of-motion (ROM) exercises to the neck and shoulders four times daily.

Keep the wrench that opens the vest attached to the client at all times. Explanation: The wrench must be attached at all times to remove the vest in case the client needs cardiopulmonary resuscitation. The vest is designed to improve mobility; the client may use a wheelchair. The pins are cleaned daily. The purpose of the vest is to immobilize the neck; ROM exercises are prohibited to the neck but should be performed to other areas.

The nurse is caring for a client with paranoid personality disorder. Which therapeutic approach would have the best outcome? Use a strict tone of voice to enforce limit setting. Avoid giving the client any choices. Employ a teaching manner to provide information. Maintain a nonemotional and matter-of-fact manner.

Maintain a nonemotional and matter-of-fact manner. Explanation: Maintaining a nonemotional, matter-of-fact manner with the client would be the most therapeutic approach when dealing with a client with paranoid personality disorder. The nurse should not attempt to talk the client out of his unfounded fears as this will merely lead to the client becoming more defensive. The nurse should provide feedback to the client's behaviors, as often the client does not realize how he comes across to others.

How can a nurse best ensure the safety of a client who has a latex allergy? Make sure that the latex allergy is properly documented. Inform the oncoming shift of the latex allergy during the shift report. Warn the client to avoid products containing latex. Instruct the client to take antihistamines daily.

Make sure that the latex allergy is properly documented. Explanation: The nurse should make sure that she properly documents the client's allergy to latex according to facility policy. She should then follow facility protocol for ensuring a latex-free environment for the client. The nurse shouldn't rely solely on verbal communication to inform the staff of the client's latex allergy. The client should be taught to avoid latex-containing products; however, the staff shouldn't rely on the client to make sure she avoids latex products. A physician's order is required for medication use, but daily antihistamine administration isn't necessary with latex allergy.

When monitoring a postpartum client 2 hours after birth of her newborn, the nurse notices heavy bleeding with large clots. Which action would the nurse perform first? Massage the fundus firmly. Perform bimanual compression. Administer ergonovine. Notify the primary health care provider.

Massage the fundus firmly. Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? Chickenpox Impetigo Measles Cholera

Measles Explanation: Measles warrants respiratory isolation, which aims to prevent disease transmission primarily over short distances through the air (droplet transmission). Other infections necessitating respiratory isolation include epiglottitis or pneumonia caused by Haemophilus influenzae, erythema infectiosum, meningitis caused by H. influenzae or meningococci, meningococcal pneumonia, meningococcemia, mumps, and pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and cholera, enteric isolation.

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan? Metallic taste Tinnitus Blurred vision Loss of smell

Metallic taste Explanation: Metronidazole commonly causes a metallic taste. Other adverse reactions include nausea, anorexia, headache, and dry mouth. The drug isn't associated with tinnitus, blurred vision, or loss of smell.

A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? Obtain vital signs. Document history of the symptoms. Assess bowel sounds and abdominal tenderness. Insert an NG tube and connect to suction.

Obtain vital signs. Explanation: The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority, and a health care provider's order is needed for an NG tube placement.

A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder? Dependent personality Passive-aggressive personality Avoidant personality disorder Obsessive-compulsive disorder

Passive-aggressive personality Explanation: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. Regarding the other answer options, the client with a dependent personality is unable to make everyday decisions and allows others to make important decisions; in addition, he often volunteers to do things that are unpleasant so that others will like him. The obsessive-compulsive personality displays perfectionism and inflexibility. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity.

Which intervention by a nurse might help prevent pressure ulcers? Placing a pillow under the client's buttocks Placing a donut cushion under the client's buttocks when he or she is sitting in a chair Placing an alternating-current mattress on the client's bed Turning and repositioning the client every 4 hours

Placing an alternating-current mattress on the client's bed Explanation: You can use a variety of foam, air-filled or water-filled devices to cushion a wheelchair, but avoid using pillows, donuts, or rubber rings, which actually cause compression. Placing an alternating-current mattress on the client's bed helps relieve pressure over bony prominences, thereby reducing the risk of pressure ulcers. The client should be turned and repositioned every 2 hours, not every 4 hours.

Two staff nurses on the urology unit are responsible for the unit schedule. The holidays are nearing, and many staff members would like to take vacation days. Which method might fairly solve the holiday staffing problem? Assign each staff member to a holiday based on seniority. Explain that no one can have a holiday off. Poll the staff to find out their preferences. Draw names from a container to determine who can be off on the holiday.

Poll the staff to find out their preferences. Explanation: The staff should have the opportunity to solve their holiday staffing issues through polling them and learning their preferences. If the unit can't be adequately staffed by considering preferences, staff should be assigned. Seniority can be considered; however, the unit must be staffed with the appropriate skill mix. It isn't cost effective to have everyone work on the holiday, and it would also be detrimental to unit morale. Drawing names from a container demonstrates a lack of leadership.

A client is admitted with Bell palsy. What should the nurse and health care team include in the plan of care? Protect client's skin integrity. Prevent complications of immobility. Provide eye care. Maintain normal bowel elimination.

Provide eye care. Explanation: Bell palsy is the disorder of cranial nerve VII (facial nerve) that causes weakness or paralysis of one side of the face. The client will also have difficulty closing the eye of the affected side. The nurse should provide eye care by using eye drops and an eye patch to prevent corneal dryness and to protect the eye from irritation. The other options are not appropriate.

Which nursing intervention is essential in caring for a client with compartment syndrome? Keeping the affected extremity below the level of the heart Wrapping the affected extremity with a compression dressing to help decrease the swelling Removing all external sources of pressure, such as clothing and jewelry Starting an I.V. line in the affected extremity in anticipation of venogram studies

Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

After her shift, a nurse remembers that she failed to document a medication that she administered. What should the nurse do? Return to the client care area and document the medication as given. Call the charge nurse and notify her that the medication was administered. Document the medication as given the next time the nurse works. Notify the physician that the medication was given but not documented as such.

Return to the client care area and document the medication as given. Explanation: The nurse should complete all documentation of care provided before leaving the client care area. If an omission occurs, the nurse should immediately return to the client care area and document the medication as given. Waiting to document could place the client at risk for receiving an extra dose of the medication. Calling the charge nurse and notifying the physician aren't appropriate actions. The nurse must take responsibility and document any care that she provides.

After undergoing a liver biopsy, the client should be placed in which position? Semi-Fowler's position Right lateral decubitus position Supine position Prone position

Right lateral decubitus position Explanation: After a liver biopsy, the client should be placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. The other positions wouldn't achieve this goal.

A client with schizophrenia becomes agitated and confronts the nurse with clenched fists. Which is the priority action of the nurse? Take the client by the hand and lead the client to the activity room for a game of cards. Step up to the client and state that this behavior is inappropriate. Call for security to take the client to a seclusion room. Speak to the client in a quiet voice and offer the client medication to help calm down.

Speak to the client in a quiet voice and offer the client medication to help calm down. Explanation: Always use the least restrictive means to calm a client. Never touch an agitated client; touch can be misinterpreted as a threat and further escalate the situation. Stepping up to an agitated client can be seen as an aggressive act. Seclusion is a last resort.

A client receiving total parental nutrition is prescribed a 24-hour urine test. The nurse delegates the collection of the specimen to the unlicensed assistive personnel (UAP). The nurse is aware that the UAP is collecting the specimen correctly when he or she initiates the collection in which instance? Start with the client's first voiding of the day Start after a client's known voiding that empties the bladder Start after the client eats breakfast Ends with the client's last evening's void as the last sample

Start after a client's known voiding that empties the bladder Explanation: When initiating a 24-hour urine specimen, have the client void, and then start timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but it's commonly started in the morning.

The nurse is preparing an in-service on hypoparathyroidism. The nurse plans to incorporate which fact about the parathyroid hormone (PTH) effect on the kidneys to enhance understanding of these clients' laboratory findings? Stimulation of calcium reabsorption and phosphate excretion Stimulation of phosphate reabsorption and calcium excretion Increased absorption of vitamin D and excretion of vitamin E Increased absorption of vitamin E and excretion of vitamin D

Stimulation of calcium reabsorption and phosphate excretion Explanation: PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn't have a role in the metabolism of vitamin E.

A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy? Support from her partner Socioeconomic status Previous health promotion activities Previous experiences with health care facilities

Support from her partner Explanation: Many factors can influence the smoothness of a pregnant client's psychosocial transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy, but these aren't the most important factors. Previous health promotion activities are least likely to affect this transition.

A client is diagnosed with severe posttraumatic stress disorder (PTSD) and is prescribed a tricyclic antidepressant. Which outcome does the nurse observe for to determine success with the prescribed regimen? The client will not have hyperactivity and purposeless movements. The client will have an increase in the ability to concentrate. The client will not experience the reenactment of the trauma. The client will suspend the grieving process.

The client will not experience the reenactment of the trauma. Explanation: Tricyclic antidepressant medication decreases the frequency of reenactment of the trauma for the client. It helps memory problems and sleeping difficulties and decreases numbing. The medication won't prevent hyperactivity and purposeless movements nor increase the client's concentration. No medication facilitates the grieving process.

A nurse is preparing to care for a client with Meniere disease. Which priority outcome should the nurse implement? The client's pain level will remain below three on a 1 to 10 scale for 8 hours. The client will experience two episodes of vomiting or less in 8 hours. The client will drink and keep down one liter of water in 6 hours. The client will not fall when attempting to stand during the 07:00 to 15:00 shift.

The client will not fall when attempting to stand during the 07:00 to 15:00 shift. Explanation: Because client safety is paramount, the nurse should work with the client to reduce the risk for injury. Vertigo, the hallmark finding in Meniere disease, is a severe rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Meniere disease does not cause pain; however, nausea and vomiting may be present. Nausea and vomiting can lead to inadequate nutrition and fluid loss, but these problems are not as important as client safety.

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? Within hours Within 2 weeks Within 1 month After induction therapy is completed

Within 2 weeks Explanation: Bone marrow depression is most likely to occur 10 days after methotrexate is administered.

A nurse reviews the health history of four clients. Which client is at greatest risk for the development of colorectal cancer? a 52-year-old client with a family history of polyposis a 32-year-old client with a history of skin cancer a 61-year-old client with a history of gastric ulcers a 42-year-old client who is prescribed 1,800-calorie, low-fat diet

a 52-year-old client with a family history of polyposis Explanation: Familial polyposis is a strong risk factor for colorectal cancer. In addition, the risk of developing colorectal cancer increases after age 50. Certain cancers, such as genital and breast cancers, but not skin cancer, are also risk factors for colorectal cancer. Gastric ulcers rarely become malignant and are not associated with colorectal cancer. A high-fat, high-calorie diet also increases the risk of colorectal cancer. Other risk factors for colorectal cancer include inflammatory bowel disease and a previous history of colorectal cancer.

A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing: a hemolytic reaction to mismatched blood. a hemolytic reaction to Rh-incompatible blood. a hemolytic allergic reaction caused by an antigen reaction. a hemolytic reaction caused by bacterial contamination of donor blood.

a hemolytic allergic reaction caused by an antigen reaction. Explanation: Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation (DIC). A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures? extent of intracranial bleeding sites of brain injury activity of the brain percentage of functional brain tissue

activity of the brain Explanation: An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by computerized tomography or magnetic resonance imaging. Percent of functional brain tissue would be determined by a series of tests.

Which instructions should the nurse include when reinforcing education to the parents about caring for a child with chickenpox? administer antibiotics as ordered administer antipruritics as ordered provide peer interaction as a distraction avoid varicella-zoster immunizations if the child has been taking aspirin

administer antipruritics as ordered Explanation: Chickenpox is highly pruritic. Preventing the child from scratching is necessary to prevent scarring and secondary infection caused by irritation of lesions. Antibiotics aren't usually used to treat chickenpox. Interaction with other children would be contraindicated due to the risk of disease transmission unless the other children have previously had chickenpox or have been immunized. Varicella-zoster immune globulin should be given to exposed children who are taking aspirin because of the possible risk of Reye syndrome.

When assessing a client suspected of having pyloric stenosis, which finding should the nurse expect? an "olive" mass in the right upper quadrant an "olive" mass in the left upper quadrant a "sausage" mass in the right upper quadrant a "sausage" mass in the left upper quadrant

an "olive" mass in the right upper quadrant Explanation: Pyloric stenosis involves hypertrophy of the circular muscle fibers of the pylorus. This hypertrophy is palpable as an "olive" mass in the right upper quadrant of the abdomen. A "sausage" mass is palpable in the right upper quadrant in children with intussusception. A "sausage" mass in the left upper quadrant doesn't indicate pyloric stenosis.

An older adult client has a wound that is not healing normally. What factor should the nurse consider for the nonhealing wound? laboratory test results kidney function test results poor wound healing expected as part of the aging process diminished immune function interfering with ability to fight infection

diminished immune function interfering with ability to fight infection Explanation: Immune function is important in the healing process, and diminished response may slow or prevent the healing process from taking place. Although immune function declines with age, there are healthy behaviors that will enhance the older adult's response to tissue trauma (e.g., nutrition, exercise). Kidney function and laboratory results are important, but are not solely responsible for health outcomes.

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect? hypertension frequent respiratory infections normal growth and development above average weight gain on the growth chart

frequent respiratory infections Explanation: Children with total anomalous pulmonary venous return defects are prone to repeated respiratory infections due to increased pulmonary blood flow. Hypertension usually occurs with coarctation of the aorta, an acyanotic defect with obstructive flow. Poor feeding and failure to thrive are also signs of a total anomalous pulmonary venous return defect, as is a thin, malnourished appearance in infants.

A client is involved in a motor vehicle crash and is being transferred to a trauma center. For which classic fractures that typically occur from trauma should the nurse gather data from? brachial and clavicle brachial and humerus humerus and clavicle occipital and humerus

humerus and clavicle Explanation: Classic fractures that occur with trauma are those of the humerus and clavicle. There are no brachial bones. Occipital bones aren't usually involved in a traumatic injury.

Which metabolic alteration characteristic might the nurse expect to be associated with growth hormone deficiency? galactosemia homocystinuria hyperglycemia hypoglycemia

hypoglycemia Explanation: The development of hypoglycemia is a characteristic finding related to growth hormone deficiency. Galactosemia is a rare autosomal recessive disorder with an inborn error of carbohydrate metabolism. Homocystinuria is an indication of amino acid transport or metabolism problems. Hyperglycemia isn't a problem in hypopituitarism.

A nurse is participating in developing the plan of care for a client in labor. When reviewing the collected data, which finding would the nurse identify as requiring additional action? urine output of 100 mL every 2 hours after epidural placement increase in blood pressure to 154/96 mm Hg during contractions decrease in respirations to 12 at the acme of contractions increase in temperature from 98° F to 99.6° F (36.2° C to 37.6° C)

increase in blood pressure to 154/96 mm Hg during contractions Explanation: During contractions, blood pressure increases, and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should assess the client's blood pressure frequently to determine if it returns to precontraction level and allows adequate fetal blood flow again. A urine output of 100 mL every 2 hours, respirations of 12, and temperature changes are normal.

A neonate born 8 weeks preterm has no spontaneous respirations but is successfully resuscitated. Within several hours, the neonate develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions and is diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. When implementing the neonate's plan of care, which intervention would be most appropriate to assist in preventing retinopathy of prematurity? covering the neonate's eyes while the neonate receives oxygen keeping the neonate's body temperature low monitoring partial pressure of oxygen (PaO2) levels Humidifying the oxygen.

monitoring partial pressure of oxygen (PaO2) levels Explanation: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature neonate receiving oxygen. Covering the neonate's eyes is appropriate for a neonate receiving phototherapy. Humidifying the oxygen aids in keeping the mucous membranes of the respiratory tract moist. Neither helps to reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the neonate should be kept warm to reduce the metabolic demands and prevent exacerbating his or her already stressed respiratory status.

A client diagnosed with schizophrenia has been taking haloperidol for 1 week when a nurse observes that the client's gaze is fixed on the ceiling. Which specific condition is the client exhibiting? akathisia neuroleptic malignant syndrome oculogyric crisis tardive dyskinesia

oculogyric crisis Explanation: An oculogyric crisis involves a fixed positioning of the eyes, typically in an upward gaze. The condition is uncomfortable but not life-threatening. Akathisia is a restlessness that can cause pacing and tapping of the fingers or feet. High fever, sweating, unstable blood pressure, stupor, and muscular rigidity are signs of neuroleptic malignant syndrome. Stereotyped involuntary movements (tongue protrusion, lip smacking, chewing, blinking, and grimacing) characterize tardive dyskinesia.

A client in the fifth month of pregnancy is having a routine clinic visit. When gathering data from the client, the nurse would be alert for which common second trimester condition? mastitis metabolic alkalosis physiologic anemia respiratory acidosis

physiologic anemia Explanation: Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. The result is physiologic anemia. Mastitis is an infection in the breast characterized by a swollen, tender breast and flulike symptoms. This condition is most commonly seen in breast-feeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.

A nurse is caring for a client diagnosed with late stage Alzheimer's disease (AD). What nursing intervention is priority? performing hygiene applying wrist restraints encouraging activities providing supervision

providing supervision Explanation: Whenever client safety is at risk, careful observation and supervision are of ultimate importance in avoiding injury. Physical contact is implemented during basic care. Applying restraints may cause agitation and combativeness. A high level of sensory stimulation may be too stimulating and distracting.

A client is receiving a tocolytic agent to help stop preterm labor contractions. The nurse would be alert for signs and symptoms of which potentially life-threatening complication? diabetic ketoacidosis hyperemesis gravidarum pulmonary edema sickle cell anemia

pulmonary edema Explanation: Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Only clients who have diabetes need to be observed for diabetic ketoacidosis. Hyperemesis gravidarum doesn't result from tocolytic use. Sickle cell anemia is an inherited genetic condition that doesn't develop spontaneously.

A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child? exercising in the physical therapy department finger painting walking in the hallways reading

reading Explanation: During a vaso-occlusive crisis, the child needs to minimize oxygen consumption by resting. Reading is a quiet, age-appropriate activity. Walking in the hallway and exercising in the physical therapy department are too strenuous for a child in vaso-occlusive crisis. Finger painting is not an appropriate activity for a 10-year-old.

The nurse is caring for a group of clients. Which activities by the nurse is the best example of the nurse as an interdisciplinary team member? performing hygiene needs for the client after incontinence administering prescribed medication in a timely manner assisting the client with ambulation to and from the bathroom recommending a physical therapy consult because of altered mobility

recommending a physical therapy consult because of altered mobility Explanation: A case manager advocates for options and services to meet the client's health needs through collaboration. Performing hygienic care for the client and administering medications are independent functions of the nurse that do not require collaboration. Assisting the client with ambulation does not require collaboration. Recommending physical therapy is the best option because it involves collaboration with the health care provider and the physical therapist.

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of hepatitis B who is jaundiced and reports weakness. Which intervention should the nurse include in the client's care plan? rest periods after small, frequent meals low-protein diet menus selected by the client regular exercise

rest periods after small, frequent meals Explanation: Rest periods and small, frequent meals are necessary for clients suspected of having hepatitis B and complaining of weakness. A diet high in protein is recommended to enhance the recovery of injured liver cells. The client is likely to need some guidance in menu selection. Choices can be made from high-protein foods. Regular exercise is too draining for a client with hepatitis B.

The nurse is obtaining data from a new client in the cardiovascular clinic. When asking about childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? croup rheumatic fever severe staphylococcal infection medullary sponge kidney

rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup—a severe upper airway inflammation and obstruction that typically strikes children ages 3 months and 3 years—may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn't damage heart structures.

A 14-year-old is seen in the pediatrician's office with a history of mild sore throat, low-grade fever, a diffuse maculopapular rash, and reports swelling of the wrists and redness in the eyes. The nurse interprets these findings as indications of which condition? rubella rubeola roseola varicella

rubella Explanation: Rubella presents with a diffuse maculopapular rash, mild sore throat, low-grade fever, and, occasionally, conjunctivitis, arthralgia, or arthritis. Rubeola is associated with high fever, which reaches its peak at the height of a generalized macular rash and typically lasts for 5 days. Roseola involves high fever and is abruptly followed by a rash. Varicella presents with fever, small erythematous macules on the trunk or scalp, which progress to papules, and clear vesicles on an erythematous base

A nurse is monitoring a client receiving doxorubicin. Which symptoms would be of greatest concern to the nurse? nausea blurred vision headache tachycardia

tachycardia Explanation: Tachycardia is the greatest concern. Doxorubicin can cause cardiotoxicity, which is damage to the heart by harmful chemicals. Symptoms include chest pain, tachycardia, and arrhythmias. The early damage occurs immediately after drug administration or within 1 to 2 days and can lead to heart failure. Symptoms of nausea, blurred vision, and a headache are not symptoms of cardiotoxicity and can be addressed at a later time.

A nurse is reinforcing teaching instructions to a client about saquinavir. Which adverse effects would the nurse include in the teaching? hypoglycemia thrombocytopenia leukocytosis hypolipidemia

thrombocytopenia Explanation: Saquinavir is an antiretroviral-protease inhibitor drug used in combination with other antiretroviral medications to help manage human immunodeficiency virus (HIV) infection. Adverse effects include hyperglycemia, bone loss, hypersensitivity reaction, hyperlipidemia, thrombocytopenia, and leukopenia.

Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder? to cope with delusional thinking to provide attention for the individual to prevent or relieve symptoms of anxiety to protect the client from family conflict

to prevent or relieve symptoms of anxiety Explanation: Anxiety and depression commonly occur in somatic symptom disorders. The client prevents or relieves symptoms of anxiety by focusing on physical symptoms. Somatic delusions occur in schizophrenia. The symptoms allow the client to avoid unpleasant activity, not to seek individual attention. Somatization in dysfunctional families shifts the open conflict to the client's illness, thus providing some stability for the family, not the client.

A 1-year-old child is brought to the emergency department with a mild respiratory infection and a temperature of 101.3° F (38.5° C). Otitis media is diagnosed. Which sign would the nurse also expect to find? excessive drooling tugging on the ears high-pitched, barking cough pearl-gray tympanic membrane

tugging on the ears Explanation: Tugging on the ears is a common sign for a child with ear pain. Pearl-gray tympanic membranes are a normal finding. Excessive drooling and a high-pitched, barking cough indicate croup. A child with otitis media usually exhibits a discolored tympanic membrane (bright red, yellow, or dull gray).

A nurse is preparing to give a neonate their first bath. Which action would be the priority? giving a tub bath using water and mild soap giving the bath right after birth using hexachlorophene soap

using water and mild soap Explanation: Use only water and mild soap on a neonate to prevent drying out the skin. Tub baths are delayed until the umbilical cord falls off. The initial bath is given when the neonate's temperature is stable. Hexachlorophene soaps should be avoided; they're neurotoxic and may be absorbed through a neonate's skin.