Pass point pt 5

When planning to administer medication to a 3-month-old infant, the nurse should keep which consideration in mind? An infant's metabolic rate is slower than an adult's. An infant's liver detoxifies drugs faster than an adult's. An infant has slower systemic drug circulation than an adult does. An infant's kidneys excrete drugs more slowly than an adult's.

An infant's kidneys excrete drugs more slowly than an adult's. Explanation: Most drugs are excreted by the kidneys. Because an infant has immature kidney function, drugs are excreted more slowly, significantly altering drug effects. An infant has a faster metabolic rate, slower drug detoxification, and faster systemic drug circulation than an adult.

Which trait is the most important for ensuring that a nurse-manager is effective? Communication skills Clinical abilities Health care experience Time management skills

Communication skills Explanation: Communication skills are a necessity for a successful nurse-manager. The manager must be able to communicate with the staff, clients, and family members. Clinical abilities, experience, and time management are also important to the manager's success, but without communication skills the manager won't be effective.

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.

To encourage the preschooler to take deep breaths for lung auscultation, which nursing action is appropriate? Allow the client to exercise in the exam room. Demonstrate what a cough is. Discuss the importance of a deep breath. Have the client blow a tissue.

Have the client blow a tissue. Explanation: The activity which has the preschooler take a deep breath in and blow out such as blowing a tissue to allow the nurse to assess the lung fields. This activity is fun and developmentally appropriate for the preschooler and accomplishes the nursing goal. Allowing for exercise may make the preschooler short of breath, but does not mean that the child will take a deep breath. Demonstration of deep breathing and discussing are not as appropriate for a preschooler.

The nurse is performing an assessment on a newly admitted client. She asks the client to remember three words: apple, house, and umbrella. Then she asks the client, "What are the three words I want you to remember?" What is the nurse assessing? Delayed recall Remote memory Attention level Immediate recall

Immediate recall Explanation: The nurse is assessing immediate recall. Delayed recall can be assessed by asking the client to repeat the same words after 5 to 10 minutes. The nurse can assess attention span by observing the client's ability to concentrate on a task for an appropriate length of time. To assess remote memory, the nurse should ask about events in the distant past, such as where the client was born.

A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (subQ). After administration, how soon should the nurse expect ephedrine take effect? Immediately In 3 minutes In 1 hour In 2 hours

Immediately Explanation: Ephedrine sulfate's onset of action is immediate when administered I.V., I.M., or subQ. Its onset of action is 15 to 60 minutes when administered orally or nasally. No noncatecholamine agent has an onset of action longer than 60 minutes.

The nurse is performing tracheal suction for a client as indicated due to a "gurgling" sound with respirations. Which nursing action is correct for performing this procedure? Apply suction during insertion of the catheter. Limit suctioning to 10 to 15 seconds' duration. Resterilize the suction catheter in alcohol after use. Repeat suctioning intervals every 15 minutes until clear.

Limit suctioning to 10 to 15 seconds' duration. Explanation: The length of time a client should be able to tolerate the suction procedure is 10 to 15 seconds. Any longer may cause hypoxia. Suctioning during insertion can cause trauma to the mucosa and removes oxygen from the respiratory tract. Suction catheters are disposed of after each use and are cleaned in normal saline solution after each pass. Suctioning, with supplemental oxygen between suctions, is performed in a minimum of 1-minute intervals in order to allow the client to rest.

Which factor is most important when planning care for a client with a bleeding disorder? Prioritization Time management Delegation Verbal communication

Prioritization Explanation: Prioritization is most important because it helps prevent treatment delays that might be life-threatening. Time management is also important because it helps the nurse provide care efficiently, but it doesn't take priority over prioritizing care. Delegation is a responsibility that exists within the context of time management. Verbal communication is also important but not as important as prioritizing client care.

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription? The client is also receiving labetalol. The client is diagnosed with intractable hiccups. The client had surgery and is restless. The client has a history of nausea and vomiting.

The client is also receiving labetalol. Explanation: The combination of antipsychotics with beta blockers may lead to an increase in the effect of both medications; therefore, caution should be taken before combining these drugs. Chlorpromazine is used in the treatment of intractable hiccups, postoperative restlessness, and nausea and vomiting.

The nurse is caring for a 28-year-old primigravida who is reporting severe back labor. Which nursing intervention is most effective in improving the comfort of the client? Patterned childbirth breathing Back massage with sacral pressure Hydrotherapy Epidural analgesia

Back massage with sacral pressure Explanation: Direct sacral pressure counteracts the pressure from the presenting part. Hydrotherapy is soothing but will not provide direct relief. Breathing will help with contraction pain but is not effective with back labor. The nurse cannot administer epidural analgesia; in addition, other forms of pain relief need to be tried before epidural analgesia.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? Infusing intravenous (I.V.) fluids rapidly as ordered Encouraging increased oral intake Restricting fluids Administering glucose-containing I.V. fluids as ordered

Restricting fluids Explanation: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A client was recently enrolled in a clinical trial for lung cancer. The client's health insurance provider asks the nurse caring for the client about the client's status, treatment regimen, and possible adverse effects of the medication she is taking. How can the nurse best respond? Provide the requested information to help the client maintain her health insurance policy. Tell the provider that she will ask the client's permission before releasing any information. Tell the provider that she'll ask the client to contact the provider. Tell the provider that a Certificate of Confidentiality was issued; therefore, no information can be released.

Tell the provider that a Certificate of Confidentiality was issued; therefore, no information can be released. Explanation: The nurse can best respond by telling the provider that a Certificate of Confidentiality was issued. This certificate forbids researchers and institutions from disclosing information identifying research subjects. The Certificate of Confidentiality helps researchers promote client participation by guaranteeing confidentiality while the client is enrolled in the study. Options 1, 2, and 3 don't ensure client confidentiality.

A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first? a 57-year-old with a clavicle fracture a 62-year-old with tachypnea a 37-year-old with a scalp laceration a 10-month-old infant who is crying uncontrollably

a 62-year-old with tachypnea' Explanation: The client with tachypnea requires immediate attention. Abnormally rapid breathing takes priority over a clavicle fracture or scalp laceration. An infant who is crying uncontrollably needs comforting, not immediate medical attention.

A nurse is reinforcing education with a client diagnosed with osteoporosis about the prescribed diet. Which food would the nurse identify as the best source of calcium? 1 cup of low-fat yogurt 1 cup of vanilla ice cream 1 oz of cheddar cheese 1 cup of cottage cheese

1 cup of low-fat yogurt Explanation: One cup of low-fat yogurt contains 415 mg of calcium. One cup of vanilla ice cream contains 170 mg; 1 oz of cheddar cheese contains 200 mg; and 1 cup of cottage cheese contains 148 mg.

A client with a history of heart disease is given a prescription for 4 grains of aspirin which comes in 81 mg per tablet. The client asks the nurse, "how many tablets should I take?" What is the nurse's best response? Record your answer using a whole number.

3 Explanation: I grain = 60 - 65mg. 4 grains = 240 -260mg. Therefore, 3 tablets will be needed. 240/81 - 2.962 rounded up to 3. 260/81 = 3.20 rounded to 3.

During a breast examination, which finding most strongly suggests that the client has breast cancer? Slight asymmetry of the breasts A fixed nodular mass with dimpling of the overlying skin Bloody discharge from the nipple Multiple firm, round, freely movable masses that change with the menstrual cycle

A fixed nodular mass with dimpling of the overlying skin Explanation: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition.

A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene? Suggest that the client drink more water Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output Do not intervene because this is a normal finding during active labor Supply the client with beverages that she enjoys drinking

Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output Explanation: This client is showing signs of dehydration; therefore, the nurse should offer the client ice chips and then ask the charge nurse to notify the physician of the client's low urine output. The client may not be able to tolerate other fluids. Oral fluids may not be sufficient to combat the dehydration. Failing to intervene may lead to severe dehydration.

The nurse is administering sublingual nitroglycerin to the client. Immediately after administration, the nurse observes the client for which possible sign or symptom? Nervousness or paresthesia Throbbing headache or dizziness Drowsiness or blurred vision Tinnitus or diplopia

Throbbing headache or dizziness Explanation: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.

A client is placed on several medications after having a myocardial infarction (MI). Which drug class is part of the medication regimen for this client that will protect the ischemic myocardium by decreasing catecholamines and sympathetic nerve stimulation? beta blockers calcium channel blockers opioids nitrates

beta blockers Explanation: Beta blockers work by decreasing catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing the heart's workload. Calcium channel blockers reduce workload by decreasing the heart rate and dilating arteries. Opioids reduce myocardial oxygen demand. Nitrates reduce myocardial oxygen consumption and decrease blood pressure.

Which aspect is most important for successful management of the child with Reye syndrome? early diagnosis initiation of antibiotics isolation of the child staging of the illness

early diagnosis Explanation: Early diagnosis and therapy are essential because of the rapid, clinical course of the disease and its high mortality. Reye syndrome is associated with a viral illness, and antibiotic therapy isn't effective to prevent the initial progression of the illness. Isolation isn't necessary because the disease isn't communicable. Staging, although important to therapy, occurs after a differential diagnosis is made.

The physician diagnoses type 1 diabetes in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe: beef insulin. fish insulin. human insulin. pork insulin.

human insulin. Explanation: Human insulin is the least antigenic form of insulin because its composition is identical to that of endogenous insulin. Animal insulins, such as beef, fish, and pork insulins, differ in composition from endogenous insulin and therefore are more antigenic. In fact, beef insulin is no longer used in the United States.

Which condition should the nurse closely monitor that may occur during chelation therapy in a child with lead poisoning? hypercalcemia hypocalcemia hyperglycemia hypoglycemia

hypocalcemia Explanation: A calcium chelating agent is used for the treatment of lead poisoning, so calcium is removed from the body with the lead. Hypocalcemia, not hypercalcemia, occurs. Hyperglycemia and hypoglycemia don't occur as a result of chelation therapy.

A client with human immunodeficiency virus (HIV) experiences frequent bouts of diarrhea. The nurse determines dietary teaching is effective when the client states which food to avoid? milk red licorice chicken soup broiled meat

milk Explanation: Clients with chronic diarrhea may develop intolerance to lactose, which may worsen the diarrhea. Although red licorice (the candy) may be eaten, black licorice (the herb) should be avoided, as it may interfere with medications, especially corticosteroids. Other foods that the client should avoid include fatty foods, other lactose-containing foods, caffeine, and sugar. Chicken soup and broiled meat may be consumed.

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator? pain level 3/10 one hour after administration of pain medication potassium 3.8 mEq/L (3.80mmol/L) before administration of intravenous fluid blood pressure of 130/90 mmHg before a brisk walk creatinine 3.5 mg/dL (309.40 µmol/L) while client is receiving dialysis

pain level 3/10 one hour after administration of pain medication Explanation: An outcome indicator describes client status at a defined time following care interventions. Pain level 3 one hour after administration of pain medication meets the definition of outcome indicator. Potassium level, blood pressure, and creatinine levels did not describe a client's status after an intervention.

A nurse is caring for a client with multiple myeloma. When assisting with the plan of care, which nursing intervention is most appropriate? monitoring respiratory status balancing rest and activity restricting fluid intake preventing bone injury

preventing bone injury Explanation: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated, not restrict the client's fluid intake.

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? calcium sodium chloride potassium

sodium Explanation: Lithium is chemically similar to sodium. If sodium levels are low, 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 an adequate amount of fluid each day. Calcium, chloride, and potassium are important for normal body functions, but sodium is most important because it can affect the absorption of lithium.

A nurse notes that a client frequently coughs while eating. The licensed practical nurse (LPN) reports this finding to the registered nurse and discusses possible options to address this problem. Based on the discussion, which health team member would the LPN expect to become involved? respiratory therapist speech therapist wound, ostomy, and continence nurse smoking cessation counselor

speech therapist Explanation: Frequent coughing while eating may indicate a problem with swallowing. Therefore, a speech therapist should be consulted. This therapist can perform a swallowing evaluation. A respiratory therapist should be consulted for problems concerning the client's breathing pattern. A wound, ostomy, and continence nurse should be consulted for ostomy and wound care issues. The nurse cannot assume that the client smokes simply because the client coughs while eating.

A client asks for information about osteoarthritis. Which statement should the nurse include when reinforcing education for the client on this condition? "Osteoarthritis is rarely debilitating." "Osteoarthritis is a rare form of arthritis." "Osteoarthritis is the most common form of arthritis." "Osteoarthritis afflicts people older than age 60."

"Osteoarthritis is the most common form of arthritis." Explanation: Osteoarthritis is the most common form of arthritis. It can afflict people of any age, although most are older adults, and it can be extremely debilitating.

The nurse is preparing the parents of an infant with hypospadias for surgery. Which statement made by the parents would indicate the need for further education? "Skin grafting might be involved in my infant's repair." "After surgery, my infant's penis will look perfectly normal." "Surgical repair may need to be performed in several stages." "My infant will probably be in some pain after the surgery and might need to take some medication for relief."

"After surgery, my infant's penis will look perfectly normal." Explanation: It's important to stress to the parents that even after a repair of hypospadias the outcome isn't a completely "normal-looking" penis. The goals of surgery are to allow the child to void from the tip of his penis, void with a straight stream, and stand up while voiding.

A 1-year-old child is diagnosed with a congenital cardiac defect after cardiac catheterization. The parents have expressed concern about activities at home. Which response by the nurse would be best when reinforcing education with these parents? "You'll have to establish strict discipline so that the child learns what activities are limited." "Allow the child to play and be active as long as the child doesn't get fatigued." "The child will only be able to play alone." "Discipline and limit-setting need to be relaxed to reduce stress and crying."

"Allow the child to play and be active as long as the child doesn't get fatigued." Explanation: Parents of a child with a congenital cardiac defect should promote normality within the limits of the child's condition after cardiac catheterization. The child needs to have appropriate limits and discipline. Being too strict with the child or overindulging him makes it hard for him to learn acceptable behavior. Children of this age are beginning to explore their world and need to be exposed to activities with other children.

A nurse is caring for a client diagnosed with bipolar disorder who is taking lithium carbonate. When reviewing information about this therapy, what instruction would be most important to reinforce with this client? "Limit your salt intake with each meal daily." "Be sure to drink at least 2 ½ quarts [2500 mL] a day." "Get outside in the warm weather to exercise when possible." "Try to slowly eliminate your caffeine intake."

"Be sure to drink at least 2 ½ quarts [2500 mL] a day." Explanation: Clients taking lithium for bipolar disorder need to maintain a high fluid intake, at least 2 ½ liters per day. Salt should not be limited because lowered sodium levels increase the risk for lithium toxicity. Exercising outdoors in warm weather is not safe; photosensitivity occurs with lithium use, and increased activity in warm weather could increase sodium loss, predisposing the client to a toxic reaction to lithium. The client does not need to reduce or eliminate intake of caffeine.

The nursing instructor asks the nursing student why would nurses be interested in a client's dietary history when administering drugs. How does the student appropriately respond? "Vegetarian diets can cause more adverse drug reactions than diets containing meat." "The number of calories consumed can alter a drug's metabolism." "Dietary intake can alter the effectiveness of some drugs." "High-sodium diets can increase the half-life of some drugs."

"Dietary intake can alter the effectiveness of some drugs." Explanation: Dietary intake can alter the effectiveness of some drugs; for example, certain antibiotics are bound and made ineffective by dairy products. A vegetarian diet doesn't cause more adverse drug reactions than does a diet containing meat. Although excessive calories may alter the distribution of a drug, caloric intake doesn't affect a drug's metabolism. Dietary intake, including sodium, doesn't affect the half-life of any drug.

The nurse is reinforcing education for the parents of a child scheduled for a closed reduction of a fracture. Which statement should the nurse include? "All fractures can be reduced." "Fracture reduction restores alignment." "Undisplaced fractures may be reduced." "Fracture reduction is usually performed with minimal discomfort."

"Fracture reduction restores alignment." Explanation: Fracture reduction restores alignment. Some fractures, such as undisplaced fractures, can't be reduced. Fracture reduction is usually painful.

An older child has received diet instruction as part of the treatment plan for type 1 diabetes. Which statement by the older child indicates to the nurse the need for additional instruction? "I will need a bedtime snack because I take an evening dose of NPH insulin." "I can eat whatever I want as long as I cover the calories with sufficient insulin." "I can have an occasional low-calorie drink as long as I include it in my meal plan." "I should eat meals as scheduled, even if I'm not hungry, to prevent hypoglycemia."

"I can eat whatever I want as long as I cover the calories with sufficient insulin." Explanation: The goal of diet therapy in diabetes is to attain and maintain ideal body weight. Each child with diabetes will be prescribed a specific caloric intake and insulin regimen to help accomplish this goal.

A client comes to the emergency department while experiencing a panic attack. Which response by the nurse would be most appropriate for the client at this time? "I'll stay with you until the attack subsides." "Everything is under control now that you're here." "You should really try to lie down and rest now." "I'll keep explaining what's happening so you can understand."

"I'll stay with you until the attack subsides." Explanation: The nurse should remain with the client until the attack subsides. If the client is left alone, he or she may become more anxious. Telling the client that everything is fine now is gives false reassurance and is never appropriate. The client should be allowed to move around and pace to help expend energy, not try to lie down and rest. The client may be so overwhelmed that he or she cannot follow lengthy explanations or instructions, so the nurse should use short phrases and slowly give one direction at a time.

The nurse is collecting data on a client before surgery. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications? "I haven't been able to eat anything solid for the past 2 days." "I've never had surgery before." "I had an operation 2 years ago, and I don't want to have another one." "I've cut my smoking down from two packs to one pack per day."

"I've cut my smoking down from two packs to one pack per day." Explanation: Smoking one pack of cigarettes per day reduces the activity of the cilia lining the respiratory tract, increasing the client's risk of ineffective airway clearance after surgery. Lack of solid foods for 2 days before surgery, no history of previous surgery, and anxiety about surgery wouldn't increase the risk of postoperative complications.

A newly hired graduate nurse is caring for a client prescribed a carminative enema. When discussing the plan of care with the nurse mentor, which appropriate information would the graduate state that provides an understanding of a carminative enema? "It is given into the rectum to help expel flatus to relieve distention." "It is given into the rectum to soften stool and lubricate the rectum." "It is used to instill antibiotics to treat infections in the rectum or anus." "It is used to administer fluids and nutrition through the rectum."

"It is given into the rectum to help expel flatus to relieve distention." Explanation: A carminative enema is given to help expel flatus to relieve bloating and distention. An oil-retention enema softens stool and lubricates the rectum. A medicated enema instills antibiotics or introduces anthelminthic agents. A nutritive enema administers fluids and nutrition through the rectum.

A client is having trouble sleeping. Which nursing intervention should the nurse suggest to the client? "Take a warm bath in the early morning, just after rising." "Maintain the same schedule for waking and sleeping." "Exercise after dinner each night to bring on fatigue." "Take frequent naps, especially in the afternoon."

"Maintain the same schedule for waking and sleeping." Explanation: Keeping the same sleep-wake schedule each day can help to maximize the ability of the client having trouble sleeping to sleep without disturbance. The client should take a warm bath in the evening before going to bed to help promote sleep, not in the morning. Exercising in the evening can cause difficulty sleeping; ideally, exercise should be performed earlier in the day. Naps should be limited to 1 or 2 hours and should be taken at the same time each day.

A nurse is instructing a client about taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands the treatment plan? "I should take corticosteroids on an empty stomach." "Taking corticosteroids will help build up my immune system." "If I don't have an asthma attack for 1 week, I can stop taking corticosteroids." "My other health care providers should be informed that I'm taking a corticosteroid."

"My other health care providers should be informed that I'm taking a corticosteroid." Explanation: The client's other health care providers need to know that the client is taking a corticosteroid to control asthma because this class of drugs can suppress inflammatory and immune responses. To reduce GI symptoms, the client should take the corticosteroid with food or milk, never on an empty stomach. Corticosteroids suppress, rather than build up, the immune system. To prevent an adrenal crisis, corticosteroid use must be discontinued by gradually reducing drug dosage, especially when the client has been on long-term corticosteroid therapy.

Parents of a 15-month-old are concerned that their child says "no" to everything. Which statement by the nurse would be an appropriate response? "Place your child in an appropriate timeout." "Ignore the behavior and the child will grow out of it." "Explain to your child that saying 'no' all the time is inappropriate behavior." "Saying 'no' is part of toddler development and is normal at this age."

"Saying 'no' is part of toddler development and is normal at this age." Explanation: Saying "no" is normal at this age. The child is attempting to exert independence. Punishing the child with a timeout is not appropriate because this is a normal stage of development. Ignoring the behavior is also inappropriate because the child needs to learn about limits. Children at this age may not understand all that they say because they repeat what they hear.

A client receiving ferrous sulfate therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide? "Take ferrous sulfate and the antacid together." "Take ferrous sulfate and the antacid at least 2 hours apart." "Avoid taking an antacid altogether." "Take ferrous sulfate and the antacid at least 1 hour apart."

"Take ferrous sulfate and the antacid at least 2 hours apart." Explanation: The nurse should instruct the client to take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be therapeutic? "That must be frightening to you. Can you tell me how you feel about it?" "There are no people living on Mars." "What do you mean when you say they're going to invade the earth?" "I know you believe the earth is going to be invaded, but I don't believe that."

"That must be frightening to you. Can you tell me how you feel about it?" Explanation: This response addresses the client's underlying fears without feeding the delusion. Refuting the client's delusion, as in option 2, would increase anxiety and reinforce the delusion. Asking the client to elaborate on the delusion, as in option 3, would also reinforce it. Voicing disbelief about the delusion, as in option 4, wouldn't help the client deal with his underlying fears.

A registered nurse (RN) is supervising a licensed practical nurse (LPN). The LPN is caring for a client diagnosed with a terminal illness. Which statement by the LPN should the RN correct? "Some clients write a living will indicating their end-of-life preferences." "The law says you have to write a new living will each time you go to the hospital." "You could designate another person to make end-of-life decisions when you can't make them yourself." "Some people choose to tell their health care provider they don't want to have cardiopulmonary resuscitation."

"The law says you have to write a new living will each time you go to the hospital." Explanation: One living will is sufficient for all hospitalizations unless the client wishes to make changes. The "No Code" or "Do Not Resuscitate" status is discussed with the health care provider, who then enters this in the client's chart. A living will explains a person's end-of-life preferences. A durable power of attorney for health care can be written to designate who will make health care decisions for the client in the event the client can't make decisions for himself.

The nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is most appropriate? "Don't worry. It won't hurt." "The test usually takes an hour." "You must sleep the whole time that the test is being done." "The special medicine will feel warm when it's put in the tubing."

"The special medicine will feel warm when it's put in the tubing." Explanation: To prepare a 4-year-old child without increasing anxiety, the nurse should provide concrete information in small amounts about nonthreatening aspects of the procedure. Saying that it won't hurt may prevent the child from trusting the nurse in the future. Explaining the time needed for the procedure wouldn't provide sufficient information. Stating that the child will need to sleep could provoke anxiety; also, it's untrue.

The parents of a child diagnosed with hypopituitarism tells the nurse they feel guilty because they should have recognized this disorder. Which statement by the nurse about children with hypopituitarism would be the most helpful?" "They're usually large for gestational age at birth." "They're usually small for gestational age at birth." "They usually exhibit signs of this disorder soon after birth." "They're usually of normal size for gestational age at birth."

"They're usually of normal size for gestational age at birth." Explanation: Children with hypopituitarism are usually of normal size for gestational age at birth. Clinical features develop slowly and vary with the severity of the disorder and the number of deficient hormones.

A 15-year-old boy wants to try out for the football team. His parents are concerned that, because he's small for his age, he might be subjecting himself to ridicule. Which response by the parents best supports the adolescent's decision-making process? "We're concerned for your safety because the other players are so much bigger than you are." "Whether or not you play football is your decision; tell us why you want to play." "Why don't we look into another sport in which body size isn't an issue." "Why do you want to play football?"

"Whether or not you play football is your decision; tell us why you want to play." Explanation: Option 2 promotes independence while demonstrating interest in the adolescent. Option 1 promotes dependence and may cause the adolescent to resent his parents. During this stage of development, it's important for the parents to foster independence. Option 3 promotes dependence and might diminish the adolescent's self-esteem; adolescents are commonly very self-conscious about their bodies. Option 4 could cause the adolescent to feel defensive, leading to hostility.

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority? Complete the client's registration information, perform an electrocardiogram (ECG), gain I.V. access, and take vital signs. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the primary care provider. Gain IV access, give sublingual nitroglycerin and a dose of aspirin, and alert the cardiac catheterization team. Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin. Explanation: Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening arrhythmias. Aspirin is given to suppress platelet aggregation. The nurse should administer nitroglycerin for chest pain. IV access is needed for medication administration, and an ECG is used to evaluate cardiac function. Registration information can be delayed until the client is stabilized. Alerting the cardiac catheterization team before completing the initial evaluation is premature.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. He also reports nausea, diaphoresis, and shortness of breath. What should the nurse do? Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician. Gain I.V. access, give sublingual nitroglycerin (Nitrostat), and alert the cardiac catheterization team. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Explanation: Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening arrhythmias. The nurse should ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain by taking vital signs. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team before completing the initial assessment is premature.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client? Antibiotic Anticoagulant Antihypertensive Anticonvulsant

Anticoagulant Explanation: During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. An antibiotic isn't given routinely during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics afterward to reduce the risk of infection. An antihypertensive agent may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should complete which of the following tasks? Ask her to void. Instruct her to drink 1 L of fluid. Prepare her for I.V. anesthesia. Ask her to lie on her left side.

Ask her to void.

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse observes the client during feeding and is concerned most with which potential development? Hyperglycemia Fluid volume excess Aspiration Constipation

Aspiration Explanation: Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake. Hyperglycemia is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation can be a problem, but it usually isn't a serious one. The client would most likely experience diarrhea.

The nurse is caring for a patient with diabetes who is lethargic and has developed rapid, deep respirations. Which action should the nurse take? Administer PRN glucagon. Start PRN oxygen at 2 L/min. Assess glucose level. Contact the health care provider.

Assess glucose level. Explanation: The rapid, deep (Kussmaul) respirations are compensatory and indicate metabolic acidosis. The nurse should assess the glucose level. There is an immediate need for correction of the acidosis with a saline bolus to prevent hypovolemia. This will be followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. Administration of glucagon will further increase the blood sugar level. The nurse should obtain all assessment information before contacting the health care provider.

A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagnosis? Somatic symptom disorder Paranoid personality Bipolar illness Obsessive-compulsive disorder (OCD)

Bipolar illness Explanation: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Paranoia is characterized by unrealistic suspiciousness and is often accompanied by grandiosity. OCD is a preoccupation with rituals and rules. Somatic symptom disorder is characterized by multiple physical symptoms that develop during times of emotional distress.

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

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 nurse is initiating an intravenous (IV) access for a client who needs an infusion of normal saline solution. Which nursing action should the nurse perform before the venipuncture? Prime the IV tubing before initiating the intravenous access. Check for latex allergy before applying the tourniquet. Check laboratory values for electrolytes. Use the biggest needle size for infusion.

Check for latex allergy before applying the tourniquet. Explanation: Priming the IV tubing is done after the access has been secured. Verifying that the client does not have latex allergy ensures the safety of the client. Laboratory values for electrolytes have no impact on IV access; however, checking platelets can indicate a tendency for bleeding during venipuncture. Using the biggest size needle is inaccurate information. Colloids require large-bore needles, but regular fluids do not.

A nurse is caring for a newly admitted client diagnosed with schizophrenia and is started on antipsychotic medication. When reviewing the client's file, which notation would alert the nurse to notify the health care provider before implementing? Client is scheduled to have a myelogram within 48 hours of admission. Client is using a barrier contraceptive. Client is 30 years of age. Client is Caucasian.

Client is scheduled to have a myelogram within 48 hours of admission. Explanation: The dye used in myelography may cause severe neuron reaction if given within 48 hours of starting a new antipsychotic medication. Client should use a barrier contraceptive because of serious potential congenital abnormalities. Antipsychotic medications are used with caution in the young and elderly clients. Certain cultural groups, such as Arab Americans, respond differently to antipsychotics. However Caucasians respond as expected.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. Which cranial nerves will the nurse assess to determine when the client is ready for a liquid diet? Cranial nerves I and II Cranial nerves III and V Cranial nerves VI and VIII Cranial nerves IX and X

Cranial nerves IX and X Explanation: Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

A home care nurse is collecting data on a geriatric client. The nurse recognizes which factor as the most common cause of medication errors in noninstitutionalized geriatric clients? Deficient knowledge Poor vision Dementia Confusion

Deficient knowledge Explanation: Deficient knowledge is the most common cause of medication errors among noninstitutionalized geriatric clients. Poor vision, dementia, and confusion can contribute to medication errors in this group, but they occur less frequently.

The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention will best help the client achieve healthy long-term sleeping habits? Administer a sleeping pill. Encourage the use of relaxation exercises. Suggest walking the halls for 30 minutes before bed. Recommend watching television before bedtime.

Encourage the use of relaxation exercises. Explanation: Relaxation exercises provide the client with a healthy way to gain control over anxiety. These exercises also produce a physiologic response that induces sleep; the response is opposite to that produced by stress. Administering a sleeping pill would provide short-term relief for sleeplessness but does not teach long-term healthy sleep habits. Suggesting that the client stay up and walk the halls will not help develop healthy sleep habits. Electronic use and television should be discontinued 1-2 hours before sleep.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder-retraining program? Establish a predetermined fluid intake pattern for the client. Encourage the client to increase the time between voiding. Restrict fluid intake to reduce the need to void. Evaluate present elimination patterns.

Evaluate present elimination patterns. Explanation: The guidelines for initiating bladder retraining in a client frustrated by urinary incontinence include evaluating the client's intake patterns, voiding patterns, and reasons for each unintentional voiding. Lowering the client's fluid intake would not reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 qt to 2 qt (1.4 to 1.9 L) of water per day. A voiding schedule should be established after evaluation.

During each prenatal checkup, the nurse obtains the client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup, that the nurse would include in the assessment? Evaluating the client for edema Measuring the client's hemoglobin (Hb) level Obtaining pelvic measurements Determining the client's Rh factor

Evaluating the client for edema Explanation: During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of pregnancy-induced hypertension. The client's Hb is measured during the first prenatal visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation. The pelvis is measured and the Rh factor determined during the first prenatal visit.

A 48-year-old client is admitted for suspected pulmonary emboli. Upon arrival in the intensive care unit, the client is alert and oriented. He insists on anxiously walking around the room. Which nursing actions take priority for this client? Initiate bed rest with the head of the bed elevated at least 45 degrees, administer supplemental oxygen, and monitor the client's respiratory status. Assess the client's vital signs, respiratory status, and neurovascular status, and initiate bed rest. Assess the client's vital signs, chest pain, and breath sounds. Auscultate breath sounds, assess the client for chest discomfort, and check his neurovascular status.

Initiate bed rest with the head of the bed elevated at least 45 degrees, administer supplemental oxygen, and monitor the client's respiratory status. Explanation: Pulmonary emboli are clots that form an obstruction of the pulmonary arterial bed. Danger signs and symptoms include changes in vital signs, pleuritic chest discomfort, tachypnea, dyspnea, and apprehension. The client must be immediately stabilized and further assessed. Continued nursing care focuses on the improvement of respiratory gas exchange, maintenance of optimal cardiac output, reduction of anxiety, and pain relief. Initiating bed rest with the head of the bed elevated to at least 45 degrees and administering supplemental oxygen as prescribed take priority because they decrease the body's oxygen demand and facilitate gas exchange. The other interventions are important but don't take priority.

vWhich nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion? Instructing the client to report any itching, swelling, or dyspnea Informing the client that the transfusion usually takes 1½ to 2 hours Documenting blood administration in the client care record Checking the client's vital signs when the transfusion ends

Instructing the client to report any itching, swelling, or dyspnea Explanation: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should monitor vital signs 5 minutes after the transfusion is started, again in 15 minutes, and then at least hourly depending on the client's condition.

A client who has a pulmonary embolism has the potential to develop chest pain. What would be the nurse's best explanation for this when reinforcing education for the client? It is the same as costochondritis. It is a result of a myocardial infarction. It is pleuritic pain due to inflammation. It is caused by referred pain from the pelvis.

It is pleuritic pain due to inflammation. Explanation: Pleuritic pain is caused by the inflammatory reaction of the lung parenchyma to the pulmonary embolism. The pain isn't associated with myocardial infarction, costochondritis, or referred pain from the pelvis to the chest.

A nurse is performing a focused cardiac assessment. In which position would the nurse ask the client to assume, so he or she can auscultate for heart sounds more easily? Supine On the right side Sitting in a chair, holding his or her breath Leaning forward

Leaning forward Explanation: The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This enables the nurse to listen after exhalation without the sound of expiration interfering. The supine position is used to visually inspect the precordium, allowing the nurse to watch the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. A left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? Note that the client reports less nausea and vomiting. Encourage oral consumption of at least 2,000 calories per day. Monitor the client's weight every day. Record fluid intake and output.

Monitor the client's weight every day. Explanation: By weighing the client with pancreatitis who has been receiving total TPN every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of present weight is one indicator of adequate nutrition. Weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. Decreased nausea and vomiting don't indicate adequate nutrition. Clients with pancreatitis have restrictions on oral intake, so encouraging increased caloric intake isn't appropriate. The nurse should record intake and output to evaluate fluid replacement, not the nutritional adequacy of TPN.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention would the nurse use to determine if TPN is providing adequate nutrition? Accelerating the infusion if it falls behind schedule Ensuring that the TPN tubing has an in-line filter Monitoring the client's weight every day Recording fluid intake and output

Monitoring the client's weight every day Explanation: By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn't accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate? Inform the physician of the lack of progress and request that discharge be delayed. Consult with family members and begin family insulin administration education. Notify the physician of the client's lack of progress and request a diabetes education department consult. Explain to the physician that a family diabetes education class might be beneficial to the client.

Notify the physician of the client's lack of progress and request a diabetes education department consult. Explanation: The nurse should notify the physician of the client's lack of progress and request a consult with the diabetes education department. The nurse can't consult the diabetes department without a physician's order. There's no need to delay the client's discharge if his condition is stable and he's physically ready for discharge. The client should be encouraged to be as independent as possible, and it isn't appropriate to consult with the family without the client's permission.

The quality control nurse is reviewing clients' charts on the medical-surgical unit. When reviewing the nursing staff nursing notes, the quality control nurse expects to find which factors? Select all that apply. Charting errors are erased. Nursing notes follow chronological order. Nursing notes are written with a #2 pencil. Nurses leave one line blank before each new entry. Nurses end each entry with the nurse's signature and title.

Nursing notes follow chronological order. Nurses end each entry with the nurse's signature and title. Explanation: Documentation should be begin at the start of the shift and continue in the order of events. The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. Erasing errors in documentation on a legal document such as a client's chart isn't permitted by law. Because a client's medical record is considered a legal document, the nurse should make all entries in ink. The nurse is accountable for the information recorded and therefore shouldn't leave any blank lines in which another health care worker could make additions.

A client is at the end of her 1st postpartum day. When assessing her uterus, the nurse expects to find the top of the fundus at the midline and at which position? At the level of the umbilicus Below the level of the symphysis pubis One fingerbreadth above the umbilicus One fingerbreadth below the umbilicus

One fingerbreadth below the umbilicus Explanation: Fundal height decreases about one fingerbreadth each postpartum day. The fundus reaches the level of the umbilicus 6 to 12 hours after birth. It descends below the level of the symphysis pubis by the 10th day after delivery. The fundus rarely is palpated above the umbilicus.

A client seeks care for low back pain of 2 weeks' duration. Which data collection finding suggests a herniated intervertebral disk? Pain radiating down the posterior thigh Back pain when the knees are flexed Atrophy of the lower leg muscles Homans' sign

Pain radiating down the posterior thigh Explanation: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, low back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

A client reports abdominal pain. During her focused assessment, which action would the nurse implement to aid in her investigation of this complaint? Using deep palpation Palpating the painful area last Palpating the painful area first Checking for warmth in the painful area

Palpating the painful area last Explanation: Palpating the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. To prepare the client, the nurse should always let the client know when the painful area will be checked. Pressure resulting from deep palpation may cause rupture of an underlying mass. Checking for warmth in the painful area offers no real information about the client's pain.

A client is receiving captopril for heart failure. Which finding indicates that the medication isn't producing the desired treatment outcome and requires the nurse to notify the physician? Skin rash Peripheral edema Dry cough Orthostatic hypotension

Peripheral edema Explanation: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and orthostatic hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

A nurse is preparing to teach a group of school-age children about injury prevention. Which intervention is most appropriate? Play group games involving sports safety equipment. Teach the children to say "no" to their peers. Encourage children to be independent. Have the children try on safety equipment.

Play group games involving sports safety equipment. Explanation: School age safety issues are related to the child moving more from the home environment to the community, decrease in fear and the increased use of tools and household items. Important safety issues that impact school-age children include burn injuries, pedestrian injuries, sport injuries and drowning. From peers, children learn how to cooperate, compete, bargain, and follow rules. Peer approval is of major importance as children look to their friends for recognition and support. The influence of peers becomes stronger as the child grows older. School-age children are subject to peer pressure, and would rather not participate in injury prevention if they must wear safety apparel that provokes taunts from peers. The nurse should discuss stylishness, comfort, and social acceptance because these are major determinants of compliance.

During rounds, a client who was admitted with gross hematuria asks the nurse about the admitting diagnosis. To facilitate effective communication, what is the nurse's best response? Ask the client what the concerns are about being hospitalized. Change the subject to something more pleasant. Provide privacy for the conversation. Give the client honest advice.

Provide privacy for the conversation. Explanation: The nurse should provide privacy for the client who asks a question about a diagnosis. Their conversation is a form of active listening, which focuses solely on the client's needs. Asking if the client has hospitalization concerns does not address the question. Changing the subject or giving advice tends to block therapeutic communication.

A client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name? Surgery Chemotherapy Radiation therapy Immunotherapy

Radiation therapy Explanation: The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer.

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate? Forcibly remove the client to prevent interaction with clients in the dayroom. Ask to speak to one of the adult alter personalities of the host personality. Remove the client from the dayroom and allow the client to play with toys. Remove the client from the dayroom and reorient in a safe place.

Remove the client from the dayroom and reorient in a safe place. Explanation: Removing the client forcibly is assault and the client is doing nothing to warrant removal at this time. Reorienting the client discourages dissociation and encourages integration. Asking to speak to an alter personality encourages dissociation. Allowing the client to play with toys would reinforce this behavior and encourage dissociation.

An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate? Schedule a weekly meeting with the children to monitor their situation. Call the mother and request a conference. Report the information to child protective services. Notify the grandfather, a local physician, to solicit help for his grandchildren.

Report the information to child protective services. Explanation: State laws dictate that day care providers, teachers, nurses, social workers, physicians, clergy, and coaches report all cases of suspected child abuse. Scheduling a weekly meeting to monitor the children's situation and calling the mother to request a conference may place the children in danger and violate the law. Notifying the grandfather breeches client confidentiality and also violates the law.

When checking a client's medication profile, the nurse notes that the client is receiving a drug that is contraindicated in clients with glaucoma. The nurse knows that this client has a history of glaucoma and has been receiving the medication for the past 3 days. What should the nurse do first? Continue to give the medication because the client has been receiving it for 3 days. Report the information to the physician to ensure client safety. File an incident report because several other staff members gave the medication. Find out whether there are extenuating reasons for giving the drug to this client.

Report the information to the physician to ensure client safety. Explanation: The nurse should report the information to the physician because the client's safety may be endangered. The fact that the client has received the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

A client with a first-degree tear and swollen perineum is 28 hours postpartum when she requests assistance with her first sitz bath. Which intervention by the nurse is necessary at this time? Recommending the use of ice packs instead of a warm sitz bath Making sure the temperature of the water is between 105° F (41.7° C) and 110° Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath Using a topical anesthetic spray before the sitz bath

Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath Explanation: The localized warmth of the water during a sitz bath commonly makes clients feel tired and unsteady. As a safety precaution, the nurse should instruct the client to call for assistance when she's ready to ambulate. Ice packs are most effective during the first 24 hours after delivery. Sitz baths should be maintained at a temperature of 100° to 105° F (37.8° to 40.6° C). A temperature of 107° F (41.7° C) might cause a burn injury. Topical medications should be applied after the sitz bath, not before, as prescribed; tissue burns may occur if topical medications are applied before the sitz bath.

While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." When creating the nursing care plan, which diagnosis would the nurse select to accurately reflect this information? Risk for impaired skin integrity related to immobility Impaired skin integrity related to immobility Constipation related to immobility Disturbed body image related to immobility

Risk for impaired skin integrity related to immobility Explanation: The information documented in the client's chart reflects the potential for impaired skin integrity. Because the client's skin is intact, the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client's feelings about self and the disease.

Which data collection finding would lead the nurse to suspect dehydration in a preterm neonate? Bulging fontanels Excessive weight gain Urine specific gravity below 1.012 Urine output below 1 ml/hour

Urine output below 1 ml/hour Explanation: Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012.

The nurse is discussing prevention of toxic shock syndrome in a group of adolescent females. Which instruction is the most important to this group? Avoid douching. Wear loose cotton underwear. Use pads, not tampons, overnight. Avoid sexual intercourse during menses

Use pads, not tampons, overnight. Explanation: The cause of toxic shock syndrome is a toxin produced by Staphylococcus aureus bacteria. It is most common in menstruating women using tampons. Tampons, particularly when left in place for more than eight hours (such as overnight), are believed to provide a good environment for growth of the bacteria, which then enter the bloodstream through breaks in the vaginal mucosa. Douching, use of loose cotton underwear, and sexual intercourse during menstruation have no direct association with toxic shock syndrome.

A 4-year-old girl is admitted to the hospital to rule out a diagnosis of leukemia. Which would be the best room assignment for the nurse to select for this child? 4-year-old girl who has rheumatoid arthritis 5-year-old boy who is having a tonsillectomy 4-year-old girl who has leukemia alone in a private room

alone in a private room Explanation: Avoiding exposure to infection is a priority for a 4-year-old child suspected of having leukemia. She requires a private room. Cross-infection could occur if this child shared a room with other children. At 4 years of age the gender of the roommate would not be significant. Remediation:

The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: start using insulin. start taking an oral antidiabetic drug. monitor her urine for glucose. be taught about diet.

be taught about diet. Explanation: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet to control her blood glucose level. Oral antidiabetic drugs aren't prescribed for pregnant clients. Urine sugars aren't an accurate indication of blood glucose levels.

A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task would be appropriate for the LPN to delegate to the CNA? giving the initial bath to a neonate bottle-feeding a 24-hour-old neonate obtaining hourly vital signs for a neonate during the transitional period changing the diaper of a recently circumcised neonate

bottle-feeding a 24-hour-old neonate Explanation: Most bottle-fed neonates have had several successful feedings by the time they are 24 hours old; therefore, the task of bottle-feeding a 24-hour-old neonate can be delegated to a CNA. An LPN should complete the initial bath to adequately collect data about the neonate's skin and to determine whether the neonate's temperature has stabilized. Neonates transitioning to extrauterine life require frequent data collection. A recently circumcised neonate must be examined carefully for evidence of abnormal bleeding. A CNA should not be given these duties because they require more advanced skill.

A client is experiencing cardiac tamponade after a chest trauma. Which type of shock will the nurse monitor for? anaphylactic cardiogenic hypovolemic septic

cardiogenic Explanation: Fluid accumulates in the pericardial sac, hindering motion of the heart muscle and causing it to pump inefficiently, resulting in signs of cardiogenic shock. Anaphylactic shock and septic shock are types of distributive shock in which fluid is displaced from the capillaries and leaks into surrounding tissues. Hypovolemic shock involves the actual loss of fluid.

A triple-lumen indwelling urinary catheter is inserted in a client for continuous bladder irrigation (CBI) following a transurethral resection of the prostate. In addition to balloon inflation, what are the functions of the three lumens? continuous inflow and outflow of irrigation solution intermittent inflow and continuous outflow of irrigation solution continuous inflow and intermittent outflow of irrigation solution intermittent flow of irrigation solution and prevention of hemorrhage

continuous inflow and outflow of irrigation solution Explanation: CBI requires insertion of a triple-lumen indwelling urinary catheter in a client following a transurethral resection of the prostate. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.

A nurse is caring for a client who is undergoing treatment for acute alcohol dependence. The client tells the nurse, "I don't have a problem. My wife made me come here." Which defense mechanism does the nurse determine the client is using? projection and suppression denial and rationalization rationalization and repression suppression and denial

denial and rationalization Explanation: The client is using denial and rationalization. Denial is the unconscious disclaimer of unacceptable thoughts, feelings, needs, or certain external factors. Rationalization is the unconscious effort to justify intolerable feelings, behaviors, and motives. The client isn't using projection, suppression, or repression. Emotions, behavior, and motives, which are consciously intolerable, are denied and then attributed to others in projection. Suppression is a conscious effort to control and conceal unacceptable ideas and impulses into the unconscious. Repression is the unconscious placement of unacceptable feelings into the unconscious mind.

A client is suspected of having cardiogenic shock. Which medication does the nurse anticipate administering to improve myocardial contractility and blood flow? dopamine enalapril furosemide metoprolol

dopamine Explanation: Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta blocker that slows the heart rate and lowers blood pressure, neither of which is a desired effect in the treatment of cardiogenic shock.

A nurse is reviewing the health care provider's prescription for a client who was admitted with fatigue, photosensitivity, and "butterfly" rash on face. Which medication would the nurse expect to find in the client's medication administration record? morphine ketoconazole hydroxychloroquine acyclovir

hydroxychloroquine Explanation: Fatigue, photosensitivity, and "butterfly" rash on face are all signs and symptoms of systemic lupus erythematosus (SLE). Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and acyclovir is an antiviral drug.

The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all of the following steps except: position the client to prevent airway obstruction. keep the client in one position to decrease bleeding. administer I.V. fluid as ordered and monitor the client for signs of fluid volume excess. maintain the client in a quiet environment.

keep the client in one position to decrease bleeding. Explanation: The nurse shouldn't keep the client in one position but rather carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

The nurse is caring for a neonate of a diabetic mother. For which condition should the nurse monitor the neonate? atelectasis microcephaly pneumothorax macrosomia

macrosomia Explanation: Neonates of diabetic mothers are at increased risk for macrosomia (excessive fetal growth) due to the increased supply of maternal glucose combined with an increase in fetal insulin. Along with macrosomia, neonates of diabetic mothers are at risk for respiratory distress syndrome, hypoglycemia, hypocalcemia, hyperbilirubinemia, and congenital anomalies. They aren't at greater risk for atelectasis or pneumothorax. Microcephaly is usually the result of cytomegalovirus or rubella virus infection.

A child has been diagnosed with acute glomerulonephritis. Based on the results of the routine urinalysis, which component is most consistent with this diagnosis? specific gravity protein blood red blood cell (RBC) casts

red blood cell (RBC) casts Explanation: Urinalysis findings consistent with acute glomerulonephritis include the presence of RBC casts. In addition, a specific gravity less than 1.030, proteinuria, and hematuria would also be findings consistent with acute glomerulonephritis. The presence of crystals in the urine typically indicates a congenital metabolic problem.

Which clinical manifestations should a nurse expect to see in a child in stage V of Reye syndrome? vomiting, lethargy, and drowsiness seizures, flaccidity, and respiratory arrest hyperventilation and coma disorientation, aggressiveness, and combativeness

seizures, flaccidity, and respiratory arrest Explanation: Staging criteria were developed to help evaluate the client's progress and to evaluate the efficacy of therapies. The clinical manifestations of stage V of Reye syndrome include seizures, loss of deep tendon reflexes, flaccidity, and respiratory arrest. Vomiting, lethargy, and drowsiness occur in stage I. Hyperventilation and coma occur in stage III. Disorientation and aggressive behavior occur in stage II of the disease.

The clinic nurse is reinforcing teaching about symptoms of cardiovascular disease (CVD) with the client. What are common symptoms associated with cardiovascular disease? shortness of breath, chest discomfort/pain, palpitations dyspnea, headache, sputum production fatigue, weight changes, edema mood swings, vomiting, fainting

shortness of breath, chest discomfort/pain, palpitations Explanation: Clinical manifestations of CVD are shortness of breath, chest discomfort/pain, dyspnea, palpitations, fainting, and peripheral skin changes such as edema.

A nurse is caring for a client who is unconscious. In which position should the nurse place the client? side-lying with the head of the bed elevated supine with the head turned to the side prone with the knees sharply flexed Trendelenburg with the body in straight alignment

side-lying with the head of the bed elevated Explanation: Positioning the unconscious client side-lying, with the head of the bed elevated, reduces the risk of airway occlusion by the tongue and aids the drainage of secretions. The other positions place the unconscious client at risk for aspiration.

A child receives prednisone after undergoing a heart transplant. Which desired outcome will the nurse monitor for? stimulate appetite suppress immune response improve wound healing prevent fluid retention

suppress immune response Explanation: The goal of prednisone for this client is to suppress the immune system, thereby preventing organ rejection. Prednisone is often used in combination with other immunosuppressant medications to prevent rejection. While corticosteroids do stimulate the appetite, that is not the desired effect for this child. Prednisone and other corticosteroids decrease wound healing; fluid retention is one of their side effects.

A 1-year-old underwent hypospadias repair yesterday; he has a urethral catheter in place and an IV. Which rationale is appropriate for administering propantheline on an as-needed basis? to decrease the chance of infection at the suture line to decrease the number of organisms in the urine to prevent bladder spasms while the catheter is present f to increase urine flow from the kidney to the ureters

to prevent bladder spasms while the catheter is present Explanation: Propantheline is an antispasmodic that works effectively on children. It prevents bladder spasms while the catheter is in place. It isn't an antibiotic and therefore won't decrease the chance of infection or the number of organisms in the urine. The drug has no diuretic effect and won't increase urine flow.

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 client with painless vaginal bleeding is suspected of having placenta previa. The nurse will assist in preparing the client for which procedure? amniocentesis speculum examination external fetal monitoring ultrasound

ultrasound Explanation: When the client and fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination should not be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring will not detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placental separation.

A client with a deep vein thrombosis (DVT) is admitted to the hospital for treatment. Which medication will the nurse administer orally to prevent further thrombus formation? warfarin heparin furosemide metoprolol

warfarin Explanation: Warfarin prevents vitamin K from synthesizing certain clotting factors. This oral anticoagulant can be given long-term. Heparin is a parenteral anticoagulant that interferes with coagulation by readily combining with antithrombin; it can't be given by mouth. Neither furosemide nor metoprolol affect anticoagulation.

Which finding would concern the nurse who's caring for an infant after a right femoral cardiac catheterization? weak right dorsalis pedis pulse elevated temperature decreased urine output slight bloody drainage around catheterization site dressing

weak right dorsalis pedis pulse Explanation: The pulse below the catheterization site should be strong and equal to the unaffected extremity. A weakened pulse may indicate vessel obstruction or perfusion problems. Elevated temperature and decreased urine output are relatively normal findings after catheterization and may be the result of decreased oral fluids. A small amount of bloody drainage is normal; however, the site must be assessed frequently for increased bleeding.