Passpoint 4

Ventral

Toward the belly

Hypotonic solution will

Hydrate

laparotomy

incision into the abdomen

Hypertonic solution will

Dehydrate

Where is the appendix located?

RLQ

xiphoid process

lower portion of the sternum

A 24-year-old client with diabetes mellitus sustains a large laceration that requires suturing. Which of the following statements indicates that the client understands wound healing? "It's so hard to predict when this scar will disappear." "My scar will fade within 4 months." "If I don't get an infection, the scar may fade in 1 to 3 years." "This procedure won't leave a scar."

"It's so hard to predict when this scar will disappear." Explanation: In a client with diabetes, wound healing is delayed and unable to be predicted. A specific time frame for healing is unrealistic as is the statement that suturing does not produce a scar.

colon

another name for the large intestine

Dorsal

back

epistaxis

nosebleed

Discharge planning is being finalized for a neonate who was born at 32 weeks' gestation and was diagnosed with retinopathy of prematurity. What should the nurse tell the parents? "An ophthalmologist will examine the baby before discharge." "You should schedule an appointment with a optometrist when the baby is 6 months old. "Before your child enters the public school system, you must arrange for an individualized educational plan with the school nurse." "Contact the local support group for the blind."

"An ophthalmologist will examine the baby before discharge." Explanation: An ophthalmologist commonly examines neonates with retinopathy of prematurity before discharge. Serial eye examinations are then necessary to determine the extent of damage. An optometrist can't provide follow-up treatment for the neonate with retinopathy of prematurity because some neonates require cryotherapy and laser photocoagulation therapy, both of which must be performed by an ophthalmologist. The parents should contact the early intervention program to set up an individualized educational plan for their child before he reaches school age. Because the neonate may have permanent vision loss, intervention before school age is important to the child's growth and development. The school nurse is only involved with individualized educational plans for children of school age. The neonate may not be blind, so suggesting a support group for the blind is inappropriate.

When determining the effectiveness of teaching a child's mother about sickle cell disease, which statement by the mother indicates the need for additional teaching? "I have started to give him some extra fluids with and between meals." "I am concerned about how the hospital staff will manage his pain." "He is going to be playing on a soccer team when he is feeling better." "I have told the child's father that both he and I are carriers of the disease."

"He is going to be playing on a soccer team when he is feeling better." Explanation: Physical and emotional stress can precipitate a sickle cell crisis. Physical exercise such as running involved in soccer would increase the child's risk for a crisis. Thus, the mother needs additional instruction about this area. Providing extra fluids with and in between meals is appropriate because it is important for the child with sickle cell disease to keep well hydrated. In addition, these children commonly have nephritis related to sickle cell disease and have difficulty conserving fluids. Therefore, they need up to 150% of normal fluid intake. Pain control is an issue in sickle cell crisis. The mother is showing concern for her child by asking how pain will be managed. Sickle cell disease is an autosomal recessive disease. For the child to have the disease, both parents must carry the recessive gene.

A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement? "I will need more frequent appointments during the remainder of the pregnancy." "Signs of any type of infection must be reported immediately." "At the earliest signs of a crisis, I need to seek treatment." "I will need to take an iron supplement even if my laboratory values are normal."

"I will need to take an iron supplement even if my laboratory values are normal." Explanation: Sickle cell disease is an autosomal recessive disorder requiring both parents to have a sickle cell trait to pass the disease to a child. Deoxygenated hemoglobin cells assume a sickle shape and obstruct tissues. Tissue obstruction causes hypoxia to the area (vaso-occlusion) and results in pain, called sickle cell crisis. This type of anemia is an inherited disorder; it is not caused by lack of iron in the diet. Iron supplementation is needed only if there is laboratory evidence of iron deficiency anemia. Self-monitoring for any type of infections or sickle cell crisis and increased frequency of antenatal care visits are part of the teaching plan of care.

A nurse is performing discharge teaching with a client who has an implantable cardioverter defibrillator (ICD) placed. Which client statement indicates effective teaching? "I'll keep a log of each time my ICD discharges." "I can't wait to get back to my football league." "I have an appointment for magnetic resonance imaging of my knee scheduled for next week." "I need to stay at least 10? away from the microwave."

"I'll keep a log of each time my ICD discharges." Explanation: The client stating that he should keep a log of all ICD discharges indicates effective teaching. This log helps the client and physician identify activities that may cause the arrhythmias that make the ICD discharge. He should also record the events right before the discharge. Clients with ICDs should avoid contact sports such as football. They must also avoid magnetic fields, which could permanently damage the ICD. Household appliances don't interfere with the ICD.

An obese client, age 65, is diagnosed with type 2 diabetes. When educating this client about his diagnosis, the nurse knows that the client will need more education when he says which of the following? Select all that apply. "If I follow my diet and exercise, I won't have diabetes any more." "If I don't keep my sugar under control, I could go into kidney failure." "I can never eat a hot fudge sundae again." "I guess I will need to stop meeting my friends at the coffee shop." "My doctor says that if I keep my weight down I probably won't have to go on insulin."

"If I follow my diet and exercise, I won't have diabetes any more." "I can never eat a hot fudge sundae again." "I guess I will need to stop meeting my friends at the coffee shop." Explanation: Patients with type 2 diabetes who follow a diet and exercise program will likely be able to achieve normal blood sugar levels, but cannot consider themselves "cured" of diabetes. Renal failure is a possible complication of uncontrolled diabetes. A person with well controlled diabetes can modify their diet to include occasional treats like ice cream if they select sugar free versions. Meeting friends for coffee is fine as long as the client does not include high sugar items along with the beverage. Type 2 diabetes can often be controlled with oral hypoglycemics.

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? "The drainage contains enzymes that are necessary for wound healing." "Antibiotics cause the cells of the tissues to produce purulent drainage." "If a wound heals on the surface but infection remains, it will open and drain." "The drainage is an indication that the sutures were not tight enough."

"If a wound heals on the surface but infection remains, it will open and drain." Explanation: Purulent drainage indicates an infection in situ. A wound may heal over the top, but when infection remains, the wound may reopen at the base and drain the discharge. A wound will continually reopen and drain purulent discharge until the infection is eradicated. It is not related to antibiotics or the ineffectiveness of the sutures.

The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative? "I get up every morning with a stuffy nose and sore throat." "Just as I get over a virus, it seems that I get another." "I have had a sore on my leg that just won't heal." "I sneeze and have watery eyes throughout the spring and summer."

"Just as I get over a virus, it seems that I get another." Explanation: Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.

The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents? "Return immediately if acute flank or mid-abdominal pain occurs." "Expect the child's weight to decrease over the next 2 weeks." "Fevers may continue to occur as the body recovers from the infection." "The infection may cause the child to have some burning with urination."

"Return immediately if acute flank or mid-abdominal pain occurs." Explanation: Acute glomerulonephritis is a major complication of streptococcal infections in children. The onset is often marked by a sudden occurrence of acute flank or mid-abdominal pain. The child may show signs of fluid retention, such as weight gain and edema. Hypertension also commonly occurs.

ICP levels: 0800: 20 0805: 18 0810: 18 0815: 16 A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond? "The client's ICP remains elevated." "The client's ICP has decreased to lower than normal limits." "The client's ICP is within normal limits." "The client's ICP was elevated but now has returned to normal."

"The client's ICP remains elevated." Explanation: A normal ICP is between 0 and 15 mm Hg. The documentation shows pressures greater than 15 mm Hg.

The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure (MAP) below 30 and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse? "Oliguria is common after a barbituate overdose. " "The body is conserving fluids to dilute the barbiturates." "There is not enough blood circulating to the kidneys." "Dialysis is needed to clear the toxins from the blood."

"There is not enough blood circulating to the kidneys." Explanation: Acute renal failure is often caused by ischemic tubular necrosis. The hypotensive state with a dangerously low mean arterial pressure means the vital organs are not being perfused adequately and are ischemic. Barbituates are cleared renally and do commonly cause oliguria after an overdose. It is also common to require hemodialysis after a severe overdose. The best answer directly and simply explains to the parents that the kidneys are not getting perfused and therefore cannot function.

The caregivers of a school-aged client with a new diagnosis of ulcerative colitis ask the nurse how to manage the condition at school. How should the nurse respond? Select all that apply. "Work with the school nurse to develop a plan." "The condition should not affect the child's schooling." "Your child will need to drink plenty of liquids at school." "Your child should keep a change of clothing at school." "You should encourage your child to not eat lunch at school."

"Work with the school nurse to develop a plan." "Your child will need to drink plenty of liquids at school." "Your child should keep a change of clothing at school." Explanation: Ulcerative colitis is a chronic inflammatory bowel disorder with exacerbations and remissions. In ulcerative colitis the colon develops continuous ulcerations that cause the common symptoms of pain and bloody diarrhea. Drugs such as antiinflammatory medications, antidiarrheals, and immunosuppressants have been used for management. A child with a chronic condition should have an action plan with the school nurse to provide needed medication and monitor symptoms. A change of clothing may be needed if clothing is soiled as a result of diarrhea. The child should be careful to avoid foods that increase symptoms (commonly raw vegetables, dairy products, and gas-producing foods such as beans, broccoli, or cabbage). Most school lunches are not individualized to a specific child. Liquids are important to prevent dehydration from diarrhea.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? "You should ask your physician about that." "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." "You may experience progressive deterioration in all voluntary muscles." "This form of muscular dystrophy is a relatively benign disease that progresses slowly."

"You may experience progressive deterioration in all voluntary muscles." Explanation: The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.

The nurse performs a routine prenatal assessment on a woman at 35 weeks gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1° F (37.3°C). Which statement is most appropriate for the nurse to make at this time? "Your pulse is low. Do you exercise a lot?" "Your blood pressure is slightly high. I will check it again before you leave." "You have a slight temperature. Do you feel hot?" "Your vital signs are all normal. I will document them on your chart."

"Your blood pressure is slightly high. I will check it again before you leave." Explanation: A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing "white coat" syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vitals are within normal range.

Cystic fibrosis

A genetic disorder that is present at birth and affects both the respiratory and digestive systems. The ducts in the pan- creas become clogged with thick, sticky mucus. This mucus blocks the enzymes from reaching food in the small intestine. ... Fortunately, pancreatic enzyme replacements or "enzymes" are available to help people with CF digest and absorb their food.

A nurse is providing health teaching to the parents of a 2-year-old child who has been diagnosed with benign febrile seizures. What is the most important information for the nurse to give the parents about this disorder? Benign febrile seizures will result in a developmental delay for the child. This diagnosis often progresses to one of epilepsy. The seizures will continue throughout the child's life. A respiratory or ear infection is usually present.

A respiratory or ear infection is usually present. Explanation: An underlying infectious process is often a stimulating factor that triggers the febrile seizures. Parents should be aware of and instructed in how to treat a febrile child. The other options are not accurate in their presentation of febrile seizures

A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first? Administer 1 liter 0.9% saline IV. Draw a complete blood count with hematocrit and hemoglobin. Obtain an abdominal X-ray. Insert an indwelling urinary catheter.

Administer 1 liter 0.9% saline IV. Explanation: The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

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

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

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care? Bilateral nasal and tympanic membrane cultures Prepare the client for transillumination of the sinuses An increased need for insulin and blood glucose monitoring Alternation of hot and cold compresses

An increased need for insulin and blood glucose monitoring Explanation: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications. Culture and sensitivity testing of purulent nasal drainage to show the causative bacterial organisms is rarely done with sinus infection, and tympanic membranes are never cultured by the nurse. Although a practitioner can illuminate the sinuses, it is not routine and is not necessary for diagnosis. Warm compresses can be applied for clients with sinusitis for comfort, however, hot compresses are not applied. Cold compresses are applied after sinus surgery, not in the case of acute infection.

What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy? Antibiotics will need to be taken for 1 to 2 weeks. Arm exercises will get rid of the cellulitis. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling. The right extremity should be lowered to improve blood flow to the forearm.

Antibiotics will need to be taken for 1 to 2 weeks. Explanation: Treatment for cellulitis includes oral or intravenous antibiotics for 1 to 2 weeks, elevation of the affected extremity, and application of warm, moist packs to the site. Arm exercises help to reduce swelling, but do not treat the infection.

Four hours after a cast has been applied for a fractured ulna, the nurse assesses that the client's fingers are pale and cool and capillary refill is delayed for 4 seconds. How should the nurse interpret these findings? Nerve impairment is developing in the fingers. Arterial blood supply to the fingers is decreased. Venous stasis is occurring in the fingers. The finding is normal for this recovery period.

Arterial blood supply to the fingers is decreased. Explanation: The pallor and cool temperature of the fingers and the decreased return time for capillary refill indicate decreased arterial blood supply to the fingers. These findings are not normal for any time in the recovery process. Nerve impairment includes numbness, tingling, and impaired movement of the fingers. Signs of venous stasis include edema and reddening of the fingers, not pallor and cool temperature.

A client suddenly loses consciousness. What should the nurse do first? Call for assistance. Assess for responsiveness. Palpate for a carotid pulse. Assess for pupillary response.

Assess for responsiveness. Explanation: A nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is inappropriate.

A client has had hoarseness for more than 2 weeks. What should the nurse do? Refer the client to a health care provider for a prescription for an antibiotic. Instruct the client to gargle with salt water at home. Assess the client for dysphagia. Instruct the client to take a throat analgesic.

Assess the client for dysphagia. Explanation: Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat.

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action? Assess the client's temperature. Notify the health care provider. Clean with antiseptic material and re-dress the site. Evaluate the client's white blood cell count.

Assess the client's temperature. Explanation: Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response, but the priority should be the temperature. The wound needs to be re-dressed, but this would occur after speaking with the health care provider in case a culture may be ordered, which would be inaccurate if the wound was cleaned first.

A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention? Assess the drainage from the stoma. Provide teaching on colostomy irrigation. Assist client in dietary planning. Encourage the client to look at the stoma.

Assess the drainage from the stoma. Explanation: Assessing the stoma is important because of the potential for surgical site infection. Teaching on irrigation and dietary planning should be performed before discharge. The client should be encouraged to look at the stoma, but this is not the priority.

When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment? Checking the dressing, drain, and amount of drainage Checking the level of pain first upon the client's return from the operating room Assessing the vital signs and oxygen saturation levels Assessing for urinary retention and the need to void

Assessing the vital signs and oxygen saturation levels Explanation: This correct response is based on principles of ABCs. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the recovery room. Checking the dressing and level of pain are both important, but not the priority.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head. Give the prescribed dose of oral phenytoin. Insert an oral suction device to remove secretions in the mouth.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head. Explanation: During a seizure, the nurse should assist the client to the floor to reduce the risk of falling and turn the client on the side to help clear the mouth of oral secretions. If available, it is appropriate to place a pillow under the client's head to protect against injury. It is inappropriate to introduce anything into the mouth during a seizure because of the risk of choking or compromising the airway; therefore, oral medications and suction devices should not be used

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? Bed rest with the affected extremity in the dependent position Bed rest with all normal activities as long as there no increased pain on the affected site Bed rest, keeping the affected extremity flat Bed rest with elevation of the affected extremity

Bed rest with elevation of the affected extremity Explanation: Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? Little is known about iron-deficiency anemia and its relationship to infection in children. Children with iron-deficiency anemia are more susceptible to infection than are other children. Children with iron-deficiency anemia are less susceptible to infection than are other children. Children with iron-deficiency anemia are equally as susceptible to infection as are other children.

Children with iron-deficiency anemia are more susceptible to infection than are other children. Explanation: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? Straw-colored urine Reduced hematocrit Clay-colored stools Elevated urobilinogen in the urine

Clay-colored stools Explanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

compartment syndrome

Compartment syndrome describes increased pressure within a muscle compartment of the arm or leg. It is most often due to injury, such as fracture, that causes bleeding in a muscle, which then causes increased pressure in the muscle. This pressure increase causes nerve damage due to decreased blood supply.

A nurse is assessing an adult who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm3 (22 × 109/L) and has petechiae on the lower extremities. What should the nurse should instruct the client to do? Increase the amount of iron in the client's diet. Apply lotion to the lower extremities. Elevate the legs. Consult the health care provider.

Consult the health care provider. Explanation: Petechiae are tiny, purplish, hemorrhagic spots visible under the skin. Petechiae usually appear when platelets are depleted. Bleeding gums or oozing of blood may accompany the petechiae, and the client should seek medical assistance immediately. Increasing iron in the diet will not improve the platelet count. Lotion will not treat the petechiae. Elevating the legs will not cause the petechiae to disappear.

While attending a support group, the parents of a child with hemophilia become concerned because they heard stories about how many children with hemophilia have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which as the most likely route of transmission of AIDS to these children? contamination of the factor VIII replacement received during bleeding episodes casual contact with a child testing positive for human immunodeficiency virus use of a contaminated needle to obtain a blood sample for type and crossmatching exposure in the waiting room to children with AIDS attending the same hematology clinic

Contamination of the factor VIII replacement received during bleeding episodes Explanation: The acquired immune deficiency syndrome (AIDS) virus is spread by direct contact with blood or blood products and by sexual contact. Children with hemophilia were at risk for AIDS in the 1980s because the factor VIII concentrate infusions were made from pooled plasma. However, factor VIII is now a recombinant synthesized factor product, which virtually eliminates the risk of contacting HIV with an infusion. There is no evidence that casual contact between infected and uninfected people transmits the human immunodeficiency virus (HIV). Exposure to others in a waiting room is considered casual contact. All venipunctures for blood specimens in hospitals and clinics are performed with sterile disposable needles. Because the needles are sterile, they cannot be a source of HIV transmission.

The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. Elevate the head of the bed to 50 degrees. Obtain daily cultures. Cover with protective dressing. Reposition the client every 2 hours. Request an alternating-pressure mattress.

Cover with protective dressing. Reposition the client every 2 hours. Request an alternating-pressure mattress. Explanation: The client has a stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria, and obtaining frequent cultures (unless prescribed otherwise) is not necessary.

A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal? Decrease intracranial pressure. Ensure a patent airway. Lower the arousal level. Produce hypoxia.

Decrease intracranial pressure. Explanation: Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis? Deficient fluid volume Excess fluid volume Decreased cardiac output Ineffective gastrointestinal tissue perfusion

Deficient fluid volume Explanation: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

Gestational Trophoblastic Disease (GTD)

Disorder classified into two types: benign (hydatidiform mole) and malignant.

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. Edema Skin pink in color Strong, bounding pulses Normal sensation Skin discoloration Skin temperature changes

Edema Skin discoloration Skin temperature changes Explanation: Lack of oxygen to nourish tissues at the capillary level causes edema, discoloration, and changes in skin temperature. Pulses will be weak or absent, and the client will experience altered sensation. Pink skin color; strong, bounding pulses; and normal sensation are signs of adequate perfusion.

12 pm: 50 mL 4 pm: 60 mL 8 pm: 60 mL 12 am: 70 mL 4 am: 70 mL 8 am: 10 mL At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), what should the nurse do next? Report the 24-hour drainage amount at 12 noon. Clamp the t-tube. Evaluate the tube for patency. Irrigate the t-tube.

Evaluate the tube for patency. Explanation: The t-tube should drain approximately 300 to 500 mL in the first 24 hours, and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 0800, the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without a prescription.

Evisceration vs Dehiscence

Evisceration is a rare but severe surgical complication where the surgical incision opens (dehiscence) and the abdominal organs then protrude or come out of the incision (evisceration). Evisceration is an emergency and should be treated as such.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? Compartment syndrome Fat embolism Infection Volkmann's ischemic contracture

Fat embolism Explanation: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

What discharge instructions should the nurse give the parents of an infant with a temporary colostomy? Flush the stoma with tap water at least once a day. Allow the diaper to absorb the colostomy drainage. Give the infant plenty of liquids to drink. Expect the stoma to become dusky red within 2 weeks.

Give the infant plenty of liquids to drink. Explanation: Because of decreased fluid reabsorption from the colon, the child with a colostomy benefits from a liberal fluid intake. Infants also dehydrate more quickly than adults do because of immature kidneys, larger body surface area, and more fluid in the extracellular spaces. Therefore, the parents need instructions about giving the infant plenty of liquids to drink. Tap water flushes of the stoma are contraindicated in infants because of the risk for absorption of free water and the potential for fluid overload. An appliance should be fitted over the stoma for stool collection to help prevent skin breakdown. The stoma should always be reddish-pink and moist. A dusky-red stoma may indicate impaired circulation to the area.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take? neurologic assessment with the Glasgow Coma Scale application of telemetry monitoring IV administration of lactated Ringer's insertion of a Foley indwelling catheter

IV administration of lactated Ringer's Explanation: The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

The nurse is caring for a neonate 4 hours after birth who has not passed meconium. When the nurse is assessing the neonate, the "wink reflex" cannot be elicited and a membrane filled with meconium is observed bulging through the anus. Which of the following defects does the nurse suspect has occurred in utero? Imperforate anus Celiac disease Intussusception Meconium plug

Imperforate anus Explanation: An imperforate anus is discovered at birth when inspection of a newborn's anal region reveals no anus, a membrane filled with black meconium protrudes from the anus, or if it is impossible to insert a rubber catheter into the rectum. A "wink" reflex (touching the skin near the rectum should make the anus contract) cannot be elicited if sensory nerve endings in the rectum are not intact. Celiac disease is a disease of gluten intolerance and the neonate would still be able to pass meconium. Intussusception is a telescoping of a portion of bowel into another portion causing obstruction. A meconium plug is a hard portion of meconium that completely blocks the intestinal lumen.

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis? Improved muscle strength after I.V. administration of edrophonium chloride. Increased weakness. Diaphoresis. Increased salivation.

Improved muscle strength after I.V. administration of edrophonium chloride. Explanation: Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which indicator of early shock? heart rate above 100 beats/minute dry, flushed skin increased urine output loss of consciousness

In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.

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

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

A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103°F (39.4°C), and oxygen saturation 84%. The central line insertion site is inflamed. After the nurse calls the rapid response team, what should the nurse do next? Place cold, wet compresses on the client's head. Obtain a portable ECG monitor. Administer a prescribed antipyretic. Insert a peripheral intravenous fluid line and infuse normal saline.

Insert a peripheral intravenous fluid line and infuse normal saline. Explanation: The client is experiencing severe sepsis, and it is essential to increase circulating fluid volume to restore the blood pressure and cardiac output. The wet compress, administering the antipyretic, and monitoring the client's cardiac status may be beneficial for this client, but they are not the highest priority action at this time. These three interventions may require the nurse to leave the client, which is not advisable at this time.

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Administering aspirin if the temperature exceeds 102° F (38.8° C) Inspecting the skin for petechiae once every shift Providing for frequent rest periods Placing the client in strict isolation

Inspecting the skin for petechiae once every shift Explanation: Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an elevated serum potassium level. What is the priority assessment action for the nurse based on the laboratory data? Monitor urine output every 4 hours. Frequently assess breath sounds. Monitor for changes in motor reflexes. Institute telemetry monitoring.

Institute telemetry monitoring. Explanation: Slow, weak, irregular pulse; lethal arrhythmias; and sudden cardiac collapse are serious complications of an elevated potassium level. The elevated value will have less impact on renal, respiratory, and neurologic function.

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

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

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed? Skin color, warmth of extremities, and mental status assessment Metabolic rate, orientation, and presence of reflexes Level of consciousness, pain level, and wound dressing Emotional status, response to anesthesia, and social support systems

Level of consciousness, pain level, and wound dressing Explanation: Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? Splint the abdomen with a pillow and call the surgeon. Apply an abdominal binder. Reinforce the existing dressing with another dressing. Lift the dressing to assess the wound.

Lift the dressing to assess the wound. Explanation: The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

The father of an 18-month-old with no previous illness, who has been admitted to a surgery center for repair of an inguinal hernia, tells the nurse that his child is having trouble breathing. The father does not think the child choked. After telling the clerk to call the rapid response team, the nurse should take which actions? Place in order from first to last. All options must be used. 1 Listen for breath sounds. 2 Perform the abdominal thrust maneuver. 3 Assess the effectiveness of the abdominal thrusts. 4 Start an intravenous infusion. 5 Notify the surgeon.

Listen for breath sounds. Perform the abdominal thrust maneuver. Assess the effectiveness of the abdominal thrusts. Start an intravenous infusion. Notify the surgeon. Explanation: The most frequent cause of respiratory distress in a toddler with no previous illness is foreign body aspiration. After having the clerk call for the rapid response team, the nurse should assess the child for breaths, and then begin abdominal thrusts. Next, the nurse (or rapid response team if present) should assess the effectiveness of the abdominal thrusts, and then start an intravenous infusion. Finally, the nurse can notify the surgeon.

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells? Liver Colon Reproductive tract White blood cells (WBCs)

Liver Explanation: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? Lung auscultation and measurement of vital capacity and tidal volume Evaluation for signs and symptoms of increased intracranial pressure (ICP) Evaluation of pain and discomfort Evaluation of nutritional status and metabolic state

Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? Pack the vagina with sterile gauze. Call the physician. Insert an indwelling catheter. Massage the fundus.

Massage the fundus. Explanation: Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which cannot occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus. The priority measure to correct postpartum hemorrhage is to massage the fundus. Packing the uterus with sterile gauze is contraindicated. The physician will have to be called but the nurse must first intervene.

The nurse is caring for an alert 2-month-old child and assesses a sunken fontanelle. Which action would be most appropriate for the nurse to take based on the assessment? Obtain the child's weight. Administer vitamin supplements. Assess for neurologic deficits. Monitor fluid intake and output.

Monitor fluid intake and output. Explanation: A sunken fontanelle in an alert child would most commonly suggest a concern with dehydration. Monitoring intake and output can help determine whether the child is receiving adequate hydration and can lead to planning further actions that could correct the situation.

The nurse is educating a group of parents about respiratory disorders in young children. One of the mothers tells the nurse that she has noticed her child's nostrils flaring when the child has a respiratory infection. The mother asks the nurse if she should be concerned. What is the most appropriate response by the nurse? "Nasal flaring occurs when a child has to work hard to breathe." "A child exhibiting nasal flaring should be seen by a physician." "When a child is breathing deeply, nasal flaring will occur." "Nasal flaring is a common respiratory symptom in children and adults."

Nasal flaring occurs when a child has to work hard to breathe." Explanation: Nasal flaring refers to the enlargement of the opening of the nostrils during breathing. Nasal flaring is seen primarily in infants and younger children. Any condition that causes the infant to work harder to obtain enough air can cause nasal flaring. Although many causes of nasal flaring are not serious, some can be life threatening. In young infants, nasal flaring can be a very important sign of respiratory distress.

A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/minute, a heart rate of 120 bpm, and a temperature of 100.8° F (38.2 ° C) rectally. The nurse is having difficulty calming the child. What should the nurse do next? Administer acetaminophen. Notify the health care provider (HCP) immediately. Allow the toddler to continue to cry. Offer clear fluids every few minutes.

Notify the health care provider (HCP) immediately. Explanation: The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/minute. The child's respiratory rate is 48 breaths/minute. Therefore the HCP needs to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is 101° F (38.6° C) or higher. Letting the toddler cry is inappropriate with croup because crying increases respiratory distress. Offering fluids every few minutes to a toddler experiencing increasing respiratory distress would do little, if anything, to calm the child. Also, the child would have difficulty coordinating breathing and swallowing, possibly increasing the risk of aspiration.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. 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 a nasogastric tube placement.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? Frontal Occipital Temporal Parietal

Occipital Explanation: The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? P wave PR interval QRS complex T wave

P wave Explanation: The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed? Apply the saturated fine-mesh gauze dressings over the wound. Apply an occlusive dressing over the saturated fine-mesh gauze dressings. Cover the saturated fine-mesh gauze dressings with an elastic bandage. Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. Explanation: The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue is usually more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because these products can prevent air circulation and hinder drying of the fine-mesh gauze.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Pallor, bradycardia, and reduced pulse pressure Pallor, tachycardia, and a sore tongue Sore tongue, dyspnea, and weight gain Angina pectoris, double vision, and anorexia

Pallor, tachycardia, and a sore tongue Explanation: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

When developing the plan of care for a client with aplastic anemia, the nurse should include which goal? Perform activities of daily living without excessive fatigue or dyspnea. Learn how to administer weekly vitamin B12 injections. Correctly demonstrate how to take prescribed anticoagulant drug therapy. Describe self-care behaviors to prevent the transmission to family members.

Perform activities of daily living without excessive fatigue or dyspnea. Explanation: With aplastic anemia, measures to conserve energy and reduce oxygen requirements are essential. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B12 in the diet. However, vitamin B12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate.

A nurse is reviewing a care plan for an infant undergoing phototherapy under blue florescent lights in an isolette for hyperbilirubinemia. Which intervention should the nurse remove from the care plan? Repositioning the infant frequently to expose all body surfaces Obtaining frequent serum bilirubin levels Shielding the infant's eyes with an opaque mask to prevent exposure to the light Performing frequent visual assessment of jaundice

Performing frequent visual assessment of jaundice Explanation: Visual assessment of jaundice is not a valid method for assessing jaundice. Serum bilirubin levels must be checked every 4 to 24 hours. Repositioning the infant and shielding the infant's eyes are appropriate interventions for an infant undergoing phototherapy and should be included in the care plan.

A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound? Opening snap Graham Steell's murmur Ejection click Pericardial friction rub

Pericardial friction rub Explanation: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

The community health nurse is providing education to a client who has given birth 74 hours earlier. What would the nurse teach the client is a sign or symptom of hemorrhage? Backache Passing a quarter-sized clot Foul smelling lochia Peripad soaked over the course of 1 hour

Peripad soaked over the course of 1 hour Explanation: With a late postpartum hemorrhage (greater than 72 hours), women report heavy bleeding and soaking a peripad in less than 1 hour. The clot could indicate placental fragments but not necessarily a postpartum hemorrhage. Clots larger than a golf ball should be reported. Leukorrhea, backache, and foul lochia may occur if a puerperal infection is the cause.

The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first? Position the client off of the ulcer. Massage the ulcerated area vigorous. Place antibiotic cream over the ulcerated area. Notify the health care provider and await orders.

Position the client off of the ulcer. Explanation: The first thing a nurse does after a bath would be to position the client off of the ulcer. The ulcer would not be vigorously massaged as this may increase the risk of skin breakdown. Antibiotic cream is not applied as there are signs of skin breakdown but not infection. The nurse would obtain ulcer measurements once the ulcer is discovered and notify the health care provider for further orders.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Prepare for gastric lavage. Obtain a urine specimen for drug screening.

Prepare to assist with ventilation. Explanation: Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection? Inadequate secondary defenses Impairment of primary body system defenses Chronic disease Proper nutrient intake

Proper nutrient intake Explanation: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

The nurse is caring for a young child who has been admitted to the hospital with pertussis. To prevent the spread of the infection, which of the following is the most important action of the nurse? Wear gloves when providing care for the child. Place the child in a negative pressure room. Provide masks for everyone entering the room. Use eye protection for direct contact with the child.

Provide masks for everyone entering the room. Explanation: Pertussis is spread via droplet transmission, so droplet precautions are necessary for the first 5 days after the child has begun medical treatment. This requires that everyone entering the room wears a mask.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first? Encourage the client to drink at least 1,000 mL/day. Provide parenteral rehydration therapy as prescribed. Turn and reposition every 2 hours. Monitor vital signs every shift.

Provide parenteral rehydration therapy as prescribed. Explanation: Initially, the extracellular fluid volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

A child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breath, and a decreased oxygen saturation level. What should the nurse do first? Suction the tracheostomy. Turn the child to a side-lying position. Administer pain medication. Perform chest physiotherapy.

Suction the tracheostomy. Explanation: Diaphoresis, increased heart rate, increased respiratory effort, and decreased oxygen saturation are signs that mucus is partially occluding the airway. Therefore, the nurse should suction the tracheostomy first to prevent full occlusion. Turning the client to a side-lying position won't remove mucus from the airway. The cleint may require pain medication after the airway has been cleared if the client's condition warrants it. Chest physiotherapy will help drain excess mucus from the lungs but not from a tracheostomy.

A child is brought to the emergency department experiencing severe right lower quadrant pain. The child's pulse and respirations are elevated, and there are localized tenderness and sluggish bowel sounds. Shortly after the initial assessment, the child states that the pain has suddenly resolved. Which of the following would the nurse suspect? The child has signs that the appendix has ruptured. The child is recovering from a mild case of gastroenteritis. The child had a bowel obstruction that has now resolved. The child was experiencing symptoms of a food allergy.

The child has signs that the appendix has ruptured. Explanation: When a child with severe right lower quadrant pain has a sudden relief of pain, a ruptured appendix should be suspected. None of the other options reflects this symptom change.

A 1-year-old child is scheduled for surgery to correct hypospadias and chordee. The nurse explains to the parents that this is the preferred time for surgical repair based on which factor? At this age, the child will experience less pain. The child is too young to have developed castration anxiety. The child will not remember the surgical experience. The repair is easier to perform after the child is toilet trained.

The child is too young to have developed castration anxiety. Explanation: The preferred time for surgery is between the ages of 6 and 18 months, before the child develops castration and body image anxiety. Children learn early on about society's emphasis on the importance of genitals. Pain is different for each child and is not related to the preferred time for repair of the hypospadias or chordee. Although the child will probably not remember the experience, this is not the basis for having the surgery at this age. If the condition is not repaired, the child will have difficulty with toilet training because urine is not eliminated through the tip of the penis.

A client is 2 days post small bowel resection with a placement of an ostomy in the right lower quadrant. The nurse is teaching the client to apply an ostomy appliance to the client's abdomen. Which of the following would indicate to the nurse that the teaching was successful? The client trims the faceplate opening giving the stoma a 1-inch (2.5 cm) border around the stoma. The client assesses the stoma and the surrounding skin before replacing the new appliance. The client chooses an antibacterial soap to scrub the fecal material around the stoma. The client states that the faceplate should be changed every other day.

The client assesses the stoma and the surrounding skin before replacing the new appliance. Explanation: For a client with an ostomy, maintaining skin integrity is a priority. The client should inspect the area with each appliance change for skin integrity issues. The client should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8 inch (.3175 cm) to 1/6 inch (.4233 cm) larger than the stoma. This size protects the skin from exposure to irritating fecal material. The client should change the appliance every 3 to 7 days. It is important to create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate.

A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. What finding would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period? The hematocrit rises from 34% to 40%. The client's experiences transient tachycardia. The blood pressure sitting is 108/62 mm Hg and standing is 94/56 mm Hg. There is an increase in cardiac output by 10%.

The hematocrit rises from 34% to 40%. Explanation: Hemoglobin and erythrocyte values vary during the early postpartum period, but they should approximate or exceed prelabor values within 2 to 6 weeks. As extracellular fluid is excreted, hemoconcentration occurs, with a concomitant rise in hematocrit. Puerperal bradycardia with rates of 50 to 70 beats per minute commonly occurs during the first 6 to 10 days of the postpartal period. A client can experience orthostatic hypotension due to blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.

The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which intervention will occur with his infant? The infant will receive clear liquids for a period of time. Formula and juice will be offered. Blood will be drawn daily to test for anemia. The infant will be allowed to go to the playroom.

The infant will receive clear liquids for a period of time. Explanation: The usual way to treat an infant hospitalized with gastroenteritis is to keep the infant nothing-by-mouth status to rest the gastrointestinal tract. The resulting fluid volume deficit is treated with intravenous fluids. When the infant's condition is controlled (e.g., when vomiting subsides), clear liquids are then started slowly. Formula and juice will be started once the infant's vomiting has subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In this situation, there is no need to test the infant's blood every day for anemia. Most likely, the infant's serum electrolyte levels would be monitored closely. Typically, an infant is placed in a private room because gastroenteritis is most commonly caused by a virus that is easily transmitted to others.

A client is experiencing acute alcohol withdrawal. What complication should the nurse anticipate based on the present condition? Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. Monitor vital signs and anticipate low blood pressure and bradycardia. The client will exhibit aphasia and ataxia. There is an increased potential for seizures and hallucinations.

There is an increased potential for seizures and hallucinations. Explanation: The seizure threshold is lowered in the brain with acute alcohol withdrawal. Associated electrolyte imbalances exist. The other choices are incorrect because the client would more likely be hypertensive and tachycardic, and the other symptoms are reflective of stroke.

Which description about crackles are true? They're grating sounds. They're high-pitched, musical squeaks. They're low-pitched noises that sound like snoring. They may be fine or coarse.

They may be fine or coarse. Explanation: Crackles result from air moving through airways that contain fluid. Audible during both inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They're classified as fine or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed visceral and parietal pleurae rub together. Wheezes occur on expiration and sometimes on inspiration. Wheezes are continuous, high-pitched, musical squeaks that result when air moves rapidly through airways narrowed by asthma or infection — or when a tumor or foreign body partially obstructs an airway. Gurgles develop when thick secretions partially obstruct airflow through the large upper airways. Loud, coarse, and low-pitched, they sound like snoring.

The nurse is explaining to a primagravida in labor that her baby is in a breech presentation, with the baby's presenting part in a left, sacrum, posterior (LSP) position. Which illustration should the nurse use to help the client understand how her baby is positioned?

This figure shows the client's baby in a breech presentation with the baby facing the pelvis on the left, the sacrum as the presenting part, and the presenting part (sacrum) is posterior in the pelvis. Figure 2 shows a vertex presentation with the baby in a left, occiput, anterior position (LOA). Figure 3 shows a vertex presentation, left, occipit, posterior (LOP). Figure 4 shows a face position with the baby in a left, mentum, transverse position (LMT).

A client with gestational hypertension receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? To lower blood pressure To prevent seizures To inhibit labor To block dopamine receptors

To prevent seizures Explanation: Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors.

ulcerative colitis vs crohn's disease

Ulcerative colitis is limited to the colon while Crohn's disease can occur anywhere between the mouth and the anus. In Crohn's disease, there are healthy parts of the intestine mixed in between inflamed areas. Ulcerative colitis, on the other hand, is continuous inflammation of the colon.

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority? Uterine massage Assessing vital signs Assisting client to empty her bladder Assisting client to left lateral position

Uterine massage Explanation: If uterine atony is noted, uterine massage should be performed to decrease the risk of postpartum hemorrhage. This intervention takes priority. If the uterus is displaced from midline, assist the client to empty her bladder. Vital signs should be taken every 15-30 minutes, but the priority action is to address the uterine atone. A position change is not indicated.

A with a pediatric client with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction? Wear the brace during waking hours. Use lotions to relieve skin irritations. Wear a form-fitting t-shirt under the brace. Bathe the skin under the brace once per week.

Wear a form-fitting t-shirt under the brace. Explanation: A form-fitting t-shirt can be worn under the brace to prevent skin irritation and collect perspiration. Braces are worn 23 hours each day. Lotions may cause irritation and should not be used. The skin under the brace should be bathed daily to help prevent irritation from the brace. The brace can be removed for bathing so all the skin can be bathed.

When an infant with pyloric stenosis is admitted to the hospital, which aspect of the plan of care should the nurse implement first? Weigh the infant. Begin an intravenous infusion. Switch the infant to an oral electrolyte solution. Orient the mother to the hospital unit.

Weigh the infant. Explanation: Unless the infant is in hypovolemic shock, obtaining a baseline weight is an important first action because the weight is used to calculate the child's fluid and electrolyte needs. The intravenous fluid rate and the amounts of electrolytes to be added to the fluid are based on the infant's weight. The weight also helps determine the infant's degree of dehydration. The intravenous infusion is initiated once the weight has been obtained. The child with pyloric stenosis typically experiences vomiting and is at risk for fluid volume deficit and metabolic acidosis. As a result, oral food and fluids are withheld, and the infant is allowed nothing by mouth. Fluid replacement is given intravenously. Orientation can wait until treatment is under way.

Your patient has had nausea, vomiting, and diarrhea for 4 days. The blood work shows this patient is dehydrated but their electrolytes have managed to stay within normal limits.

What kind of solution is this patients blood? Hypertonic What kind of fluid would you give this patient? Isotonic at first such as 0.9% NaCl (expand their volume and give them more to move or shift around) Hypotonic second, usually 0.45% NaCl (shift the fluid into the cells)

Your patient comes in with bilateral +2 pitting edema on the lower extremities. The blood work confirms congestive heart failure (CHF).

What kind of solution is this patients blood? Hypotonic What kind of fluid would you give this patient? Hypertonic (shifts fluid out of the extracellular space and into the vein, to be filtered out in the kidneys)

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client? With the affected hip flexed acutely With the leg on the affected side abducted With the leg on the affected side adducted With the affected hip rotated externally

With the leg on the affected side abducted Explanation: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.

A nurse is teaching a new mother about intussusception. Which signs and symptoms should the nurse include? abdominal distension and vomiting hard black stools high fever and loss of appetite loss of bowel sounds

abdominal distension and vomiting Explanation: Intussusception occurs when a portion of the bowel slides into the next, like the pieces of a telescope. When this occurs it can create a blockage in the bowel, with the walls of the intestines pressing against one another. This leads to abdominal swelling, inflammation, and decreased blood flow to the part of the intestines involved. Additional symptoms include vomiting, passing of stools mixed with blood and mucus, and grunting due to pain.

Crohn's disease

a chronic autoimmune disorder that can occur anywhere in the digestive tract; however, it is most often found in the ileum and in the colon

leukorrhea

a profuse, whitish mucus discharge from the uterus and vagina

A client with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the client's history, the nurse considers which information to be most important? a fever that started 3 days ago lack of interest in food a recent episode of pharyngitis vomiting for 2 days

a recent episode of pharyngitis Explanation: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the client may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.

Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which problem? poor ability to concentrate urine little skin pigment to prevent sunburn poorly functioning temperature control center abnormally high salt loss through perspiration

abnormally high salt loss through perspiration Explanation: One characteristic of cystic fibrosis is the excessive loss of salt through perspiration. Extra salt is almost always necessary during warm weather or any other time the child with cystic fibrosis perspires more than usual. In the child with cystic fibrosis, the functioning of the sweat glands is the problem, causing abnormal amounts of salt to be lost with perspiration. The ability to concentrate urine is not the problem. Little skin pigment is not a condition associated with cystic fibrosis. A poorly functioning temperature control center is not a condition related to cystic fibrosis.

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate? decreased generalized edema within 8 hours decreased urinary output during the first 24 hours sedation and decreased reflex excitability within 48 hours absence of any seizure activity during the first 48 hours

absence of any seizure activity during the first 48 hours Explanation: The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) resulting from pulmonary stenosis? educating the family about the signs and symptoms of CHF administering enoxparin to improve left ventricular contractility assessing heart rate and blood pressure every 2 hours administering furosemide to decrease systemic venous congestion

administering furosemide to decrease systemic venous congestion Explanation: Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Furosemide is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF, but treating the client's CHF is the priority. Enoxaparin is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF, but assessments do not treat the problem.

Hashimoto's disease

an autoimmune disease in which the body's own antibodies attack and destroy the cells of the thyroid gland causing hypothyroidism Hashimoto's disease is a condition in which your immune system attacks your thyroid, a small gland at the base of your neck below your Adam's apple. ... Inflammation from Hashimoto's disease, also known as chronic lymphocytic thyroiditis, often leads to an underactive thyroid gland (hypothyroidism). Leading cause of hypothyroidism in the US

Graves disease

an autoimmune disorder that is caused by hyperthyroidism and is characterized by goiter and/or exophthalmos

Posterior

back

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? being male being in the 95th percentile for height and weight having a mother who did not receive prenatal care until the second trimester of her pregnancy being an infant

being an infant Explanation: Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. In later childhood and adolescence, morbidity and mortality are higher in females than males. A higher-than-average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis. Prenatal care is unrelated to tuberculosis.

When performing the Heimlich maneuver on a conscious adult victim, where should the nurse deliver the rescuer inward and upward thrusts? above the umbilicus at the level of the xiphoid process over the victim's midabdominal area below the xiphoid process and above the umbilicus

below the xiphoid process and above the umbilicus Explanation: The thrusts should be delivered below the xiphoid process, but above the umbilicus, to minimize the risk of internal injuries.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be: coffee-ground-like. clay-colored. black and tarry. bright red.

black and tarry. Explanation: Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. His urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the primary care provider? blood pressure of 80/45 mm Hg body temperature of 102.8° F (39.3° C) pulse rate of 85 bpm respiratory rate of 28 breaths/minute

body temperature of 102.8° F (39.3° C) Explanation: Temperature of 102.8° F (39.3° C) is elevated, suggesting an infection. The nurse should notify the primary care provider. The child is displaying signs and symptoms of nephrotic syndrome. With this disorder, blood pressure is characteristically normal or slightly low. The other vital signs are likely to be normal unless edema causes respiratory distress and respirations increase and become labored. The blood pressure reading, heart rate, and respiratory rate here are within the normal range for a toddler. A pulse rate of 85 bpm is normal for a toddler. In nephrotic syndrome, the pulse rate would be normal unless other problems arise. A respiratory rate of 28 is normal for a toddler. In nephrotic syndrome, the respiratory rate would be normal unless edema causes respiratory distress and the respirations increase and become labored.

When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse? carotid artery femoral artery brachial artery radial artery

brachial artery Explanation: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heartbeat.

The client is experiencing parasympathetic responses to pain. What responses should the nurse assess the client for? Select all that apply. increased blood pressure bradycardia weakness dilated pupils diaphoresis

bradycardia weakness Explanation: To assess pain properly, the nurse must consider the client's description and the nurse's observations of the client's physical and behavioral responses. Physiologic responses may be sympathetic or parasympathetic in nature. Sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness.

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action? holding the infant prone while feeding holding the infant in her lap to burp placing the infant prone after the feeding burping the infant during and after the feeding

burping the infant during and after the feeding Explanation: Infants with colic should be burped frequently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and the intestines. Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burping the infant with colic is to hold the infant at the mother's shoulder so that the infant's abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant's abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings.

While performing cardiopulmonary resuscitation (CPR) on a 5-year-old child, the nurse palpates for a pulse. Which site is best for checking the pulse during CPR in a 5-year-old child? femoral artery carotid artery radial artery brachial artery

carotid artery Explanation: Checking the carotid artery pulse in a child during CPR provides information about perfusion of the brain. The brachial pulse is checked in an infant because the infant's short and typically fat neck makes it difficult to palpate the carotid pulse. The femoral and radial arteries might indicate perfusion to the peripheral body sites, but the critical need is for adequate circulation to the brain.

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)? delayed puberty chest pain with dyspnea poor weight gain large, foul-smelling, and bulky stools

chest pain with dyspnea Explanation: Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed, but respiratory complications are the greatest concern.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis.

cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

gastric lavage

cleansing procedure in which the stomach is irrigated with a prescribed solution

When the nurse is assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? aching pain in the left calf burning pain in the left calf numbness and tingling in the left leg coldness of the left foot and ankle

coldness of the left foot and ankle Explanation: Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction.

Which is characteristic of cardiogenic shock? hypovolemia increased cardiac output decreased myocardial contractility infarction

decreased myocardial contractility Explanation: Cardiogenic shock occurs when myocardial contractility decreases and cardiac output greatly decreases. The circulating blood volume is within normal limits or increased. Infarction is not always the cause of cardiogenic shock.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called: functional hearing loss. fluctuating hearing loss. sensorineural hearing loss. conductive hearing loss.

conductive hearing loss. Explanation: Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

The nurse is caring for an infant diagnosed with a congenital heart disease. Which of the following concerns should be a priority for the nurse to address with the parents when discussing the child's condition? congestive heart failure kidney failure nutritional concerns body temperature regulation

congestive heart failure Explanation: Parents of children with congenital heart disease need information about congestive heart failure because congestive heart failure is generally the first consequence seen in a child with congenital heart disease. In addition to often being the primary diagnosis, it can also remain an ongoing complication. Kidney failure, eating concerns, and intermittent elevated temperature may inevitably present as complications, but not initially.

A client is admitted for treatment of Prinzmetal's angina. When developing this client's care plan, the nurse should keep in mind that this type of angina can result from: activities that increase myocardial oxygen demand. an unpredictable amount of activity. coronary artery spasm. the same type of activity that caused previous angina episodes.

coronary artery spasm. Explanation: Prinzmetal's angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; anginal pain becomes increasingly severe.

A client presents with a congenital heart defect and increased pulmonary blood flow. Which signs or symptoms will alert the nurse that congestive heart failure is occurring? Select all that apply. weight loss coughing tachypnea with feeding polyuria course breath sounds

coughing tachypnea with feeding course breath sounds Explanation: Congestive heart failure is caused by increased pulmonary blood flow or obstruction to the systemic blood outflow tract. Signs of this occurring would be an increase in weight, coughing, difficulty or fast breathing (tachypnea) with feeding, oliguria, and course breath sounds.

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

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

After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. This assessment indicates the client is: exhibiting normal signs of an ovulatory stimulant. demonstrating signs of hyperstimulation syndrome. is probably pregnant. is having a reaction to the menotropins.

demonstrating signs of hyperstimulation syndrome. Explanation: Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing care includes emotional support to reduce anxiety and management of symptoms. These signs aren't signs of pregnancy and aren't normal reactions to ovulatory stimulants.

A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child's health care provider (HCP)? vomiting after lunch difficulty in recalling the day of the week blood pressure of 102/62 mm Hg 100 mL of concentrated urine voided at one voiding

difficulty in recalling the day of the week Explanation: A decrease or change in the level of consciousness is an early indication of increased intracranial pressure (ICP) and should be reported to the child's HCP as soon as possible to try and control the pressure so that it does not increase further. Vomiting can be a sign of increased ICP that occurs with a brain tumor, but it usually occurs unrelated to food and in the morning upon arising. Blood pressure increases with a brain tumor due to pressure on the brain stem. Concentrated urine is a sign of dehydration and is not related to the signs of a brain tumor.

The nurse is auscultating the lung sounds of a client with long-standing emphysema. The nurse is most likely to detect: fine crackles. diminished breath sounds. stridor. pleural friction rub.

diminished breath sounds. Explanation: In emphysema, the anteroposterior diameter of the chest wall is increased. As a result, the client's breath sounds may be diminished. Fine crackles are present when there is fluid in the lungs. Stridor occurs as a result of a partially obstructed larynx or trachea; stridor can be heard without auscultation. A pleural friction rub is present when pleural surfaces are inflamed and rub together.

A 10-month-old child with bronchiolitis with a prescription to wean oxygen was weaned to room air 2 hours ago. During a feeding, the nurse notes that the child is exhibiting an increased respiratory rate, is becoming more irritable, and is using accessory muscles to breathe. The pulse oximeter is reading 91%. The first actions of the nurse should be to: discontinue the feeding and place the child back in the tent. assess the pulse rate and respirations and notify the primary care provider. call for a stat PRN albuterol treatment and then complete the feeding. suction the child's nose with a bulb syringe and reassess the pulse oximeter.

discontinue the feeding and place the child back in the tent. Explanation: The child who has increasing respiratory difficulty after being weaned from oxygen should be placed back on oxygen. The child's pulse rate will most likely be increased. The nurse does not need to notify the primary care provider of the child's status unless no improvement occurs after the child is back on oxygen. Albuterol has limited use in the treatment of bronchiolitis and can be associated with vomiting if given too close to feedings. Unless the child has blocked nasal passages, there is no reason to suction the nares.

On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: blood pressure is 148/92 mm Hg. heart rate is 98 bpm. respirations are 32 breaths/min. O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. breath sounds are coarse and wet bilaterally with a loose, productive cough. The client has voided 100 mL very dark, concentrated urine during the last 4 hours. bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription? antihypertensive medication additional fluid intake diuretic medication increased oxygen liter flow rate

diuretic medication Explanation: The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg, and her pulse rate is 120 bpm. The nurse notifies the primary health care provider (HCP) immediately because of the possibility of which complication? ectopic pregnancy. abruptio placentae. gestational trophoblastic disease. complete abortion.

ectopic pregnancy. Explanation: The client's signs and symptoms indicate a probable ectopic pregnancy, which can be confirmed by ultrasound examination or by culdocentesis. The HCP is notified immediately because hypovolemic shock may develop without external bleeding. Once the fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae would be manifested by a board-like uterus in the third trimester. Gestational trophoblastic disease would be suspected if the client exhibited no fetal heart rate and symptoms of pregnancy-induced hypertension before 20 weeks' gestation. A client with a complete abortion would exhibit a normal pulse and blood pressure with scant vaginal bleeding.

The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment? electrocardiogram (ECG) electrodes pulse oximeter blood pressure cuff Doppler for pulse check

electrocardiogram (ECG) electrodes Explanation: The nurse should first apply the ECG electrodes to the client's chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a code situation using arterial blood gas analysis. The client's blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.

introitus

entrance to the vagina

A 6-year-old child has tested positive for West Nile virus infection. The nurse suspects the child has the severe form of the disease because of which signs and symptoms? fever, rash, and malaise anorexia, nausea, and vomiting fever, muscle weakness, and change in mental status fever, lymphadenopathy, and rash

fever, muscle weakness, and change in mental status Explanation: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise, anorexia, nausea and vomiting, and lymphadenopathy suggest the mild, not severe, form of West Nile virus infection.

Anterior

front

A parent brings a preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment does the nurse anticipate? administration of a dose of ipecac syrup insertion of a nasogastric tube and administration of an antacid I.V. infusion of normal saline solution gastric lavage and administration of activated charcoal

gastric lavage and administration of activated charcoal Explanation: The healthcare provider will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended, and an antacid is not an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself is not effective in eliminating the poisonous substance.

puerperal infection

genital tract infection following childbirth

A client makes a routine visit to the prenatal clinic. Although she's 14 weeks pregnant, the size of her uterus approximates an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: an empty gestational sac. grapelike clusters. a severely malformed fetus. an extrauterine pregnancy.

grapelike clusters. Explanation: In a client with gestational trophoblastic disease, an ultrasound performed after the third month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy occurs with an ectopic pregnancy.

Before the surgical repair of a detached retina, the client is placed on bed rest in a supine position. This position has been effective if it: helps reduce intraocular pressure. facilitates drainage from the eye. keeps the client safe while confined to bed. helps prevent further retinal detachment or tearing.

helps prevent further retinal detachment or tearing. Explanation: The client's position is determined by the location of the retinal tear. The rationale for rest is the hope that the retina will fall back into place as much as possible before surgery, which will facilitate adherence of the retina to the choroid. Increased intraocular pressure is not a problem in retinal detachment. There should be no external drainage from the eye. The client is placed on bed rest to facilitate treatment of the eye, not to keep the client safe.

Cytomegalovirus (CMV)

herpes-type virus that usually causes disease when the immune system is compromised

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder? phimosis hydrocele epispadias hypospadias

hypospadias Explanation: The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has: a lower percentage of body water than an adult. a lower daily fluid requirement than an adult. a more rapid respiratory rate than an adult. immature kidney function.

immature kidney function. Explanation: Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant actually has a greater percentage of body water as well as higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid balance in an infant.

An autograft is taken from the client's left leg. The nurse should care for the donor site by: covering it with an occlusive dry dressing. keeping the site clean and dry. applying a pressure dressing. wrapping the extremity with an elastic bandage.

keeping the site clean and dry. Explanation: It is important to keep donor sites clean, dry, and free of pressure. Single-layer gauze dressings impregnated with petroleum, scarlet red, or biosynthetic dressings may be used to cover the donor site as it heals. If cared for properly, the site usually heals in 1 to 2 weeks. Occlusive dressings are not used because they do not keep the donor site dry and open to the air. A pressure dressing is not needed over the donor site and can impair healing. Elastic bandages are not used because they constrict circulation and can impede healing.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected? edema around the ankle loss of hair on the lower leg thin, soft toenails warmth in the foot

loss of hair on the lower leg Explanation: The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.

Kaposi's sarcoma

malignant tumor of the blood vessels associated with AIDS

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately? mouth breathing foul odor from the mouth moderate intercostal retractions irregular respirations while awake

moderate intercostal retractions Explanation: Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician. Mouth breathing and a foul odor from the mouth aren't cause for concern. Irregular respirations while awake are not an unusual finding in a young child.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: thyroid storm. cretinism. myxedema coma. Hashimoto's thyroiditis.

myxedema coma. Explanation: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

A mother brings her child to the emergency department after the child has taken "some white pills just a short while ago." When assessing the child, what should lead the nurse to determine that the pills taken were most probably acetaminophen? nosebleed seizure activity nausea and vomiting deep, rapid respirations

nausea and vomiting Explanation: Acetaminophen is a common drug poisoning agent in children. Symptoms seen in the first 24 hours include nausea and vomiting, anorexia, malaise, and pallor. Nosebleed and deep, rapid respirations are seen in salicylate poisoning. Seizure activity is not commonly seen with acetaminophen poisoning.

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should: notify the health care provider (HCP). tell the client that this is normal because intracranial pressure (ICP) fluctuates throughout the day. instruct the client to increase fluid intake prior to going to bed to prevent headache in the morning. advise the client to request pain medication from the health care provider (HCP).

notify the health care provider (HCP). Explanation: ICP is highest in the early morning, and the client with hydrocephalus may be experiencing signs of increased ICP that need to be treated. The increased ICP is not related to fluid levels, and the nurse should not advise the client to increase fluid intake. While ICP does fluctuate during the day, it is highest in the morning, and the nurse should notify the HCP. Pain medication will not treat the potentially increasing ICP and may mask important signs of increasing ICP.

The nurse should conduct a focused assessment for the client with suspected bladder cancer for which common sign of the disease? suprapubic pain painful voiding painless hematuria urine retention

painless hematuria Explanation: Painless hematuria is the most common clinical finding in bladder cancer. Other symptoms include urinary frequency, dysuria, and urinary urgency, but these are not as common as hematuria. Suprapubic pain and urine retention do not occur in bladder cancer.

A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer to call 911, what intervention should happen first? performing the Heimlich maneuver until the child starts choking or coughing opening the child's mouth and attempting to give 2 breaths delivering five back blows followed by five chest thrusts performing chest compressions with the heel of one hand 30 times

performing chest compressions with the heel of one hand 30 times Explanation: According to the American Heart Association (Heart and Stroke Foundation of Canada), when a child between 1-and 8-years-old is unconscious and believed to have an obstructed airway, the child should first be laid upon a hard surface, and 30 chest compressions should be given. Delivering five back blows followed by five chest thrusts is appropriate for an infant less than 1-year-old. Performing the Heimlich maneuver is appropriate when the child is still conscious. Attempting to give breaths should happen after the chest compressions. The chest compressions are believed to help expel the obstruction.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: sodium. potassium. magnesium. phosphorus.

phosphorus. Explanation: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

When caring for a toddler with epiglottitis, the nurse should first: examine the client's throat. place a tracheotomy tray at the bedside. administer I.V. fluids. administer antibiotics.

place a tracheotomy tray at the bedside. Explanation: Placing a tracheotomy tray at the bedside should take priority because acute epiglottitis is an emergency situation in which inflammation can cause the epiglottis to swell, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation. The nurse should never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottitis are present because this maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are the priority. Only after a patent airway is secured can antibiotics be given to treat Haemophilus influenzae, a common cause of acute epiglottitis.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: progressively deeper breaths followed by shallower breaths with apneic periods. rapid, deep breaths with abrupt pauses between each breath. rapid, deep breaths and irregular breathing without pauses. shallow breaths with an increased respiratory rate.

progressively deeper breaths followed by shallower breaths with apneic periods. Explanation: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

ankylosis

the loss, or absence, of mobility in a joint due to disease, injury, or a surgical procedure

Venous stasis

the temporary cessation or slowing of the venous blood flow

A nurse should expect a client with hypothyroidism to report: increased appetite and weight loss. puffiness of the face and hands. nervousness and tremors. thyroid gland swelling.

puffiness of the face and hands. Explanation: Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort? brown discoloration of the skin with edema in the lower left leg dark, protruding veins of both legs that are uncomfortable when standing absence of pain or swelling when the client dorsiflexes the left foot red, warm, palpable linear cord along the vein that is painful on palpation

red, warm, palpable linear cord along the vein that is painful on palpation Explanation: Superficial thrombophlebitis is associated with pain, warmth, and erythema. The nurse can request a prescription for warm packs to relieve the pain. Venous insufficiency causes edema and a brown discoloration of the lower leg. Varicose veins are dark, protruding veins, and symptoms of discomfort increase with standing. Pain on dorsiflexion of the foot indicates deep vein thrombosis; the client does not indicate having this pain.

A 14-month-old child returns from surgery for an undescended testicle. When planning for the child's discharge, the nurse should remind the parents to observe their child for: redness or swelling at the incision site. ability to take clear liquids well. normal bowel movement within 24 hours. ability to ambulate.

redness or swelling at the incision site. Explanation: As with any surgery or invasive procedure, a priority goal at this time would be to prevent infection at the operative site. The nurse should instruct the parents to observe the incision and report redness or swelling. The child can usually begin to take fluids and solids shortly after surgery and should be able to tolerate them prior to discharge. Defecation is not a usual problem after this type of surgery because the bowel is not involved. Usually the child can get up as soon as comfort allows.

When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply. right ventricular hypertrophy aortic valve stenosis ventricular septal defect overriding aorta atrial septal defect pulmonary stenosis

right ventricular hypertrophy ventricular septal defect overriding aorta pulmonary stenosis Explanation: Tetralogy of Fallot involves four defects: right ventricular hypertrophy, ventricular septal defect, overriding aorta, and pulmonary stenosis. Aortic valve stenosis and atrial septal defect are not components associated with this condition

A client has had a total hip replacement. Which sign most likely indicates that the hip has dislocated? abduction of the affected leg loosening of the prosthesis external rotation of the affected leg shortening of the affected leg

shortening of the affected leg Explanation: The most likely indication of a dislocated hip is a shortening of the affected leg. Other indications of dislocation include increasing pain, loss of function to the extremity, and deformity. Abduction of the leg after total hip replacement is a desirable position to prevent dislocation. Loosening of the prosthesis does not necessarily indicate that the hip has dislocated. External rotation of the hip can occur without the hip's being dislocated. However, a neutral position of rotation is the desired position.

Which respiratory pattern indicates increasing intracranial pressure in the brain stem? slow, irregular respirations rapid, shallow respirations asymmetric chest excursion nasal flaring

slow, irregular respirations Explanation: Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations. Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they: do not require specialized equipment. strengthen the muscles while keeping the joints stationary. involve clients in their own care and thus improve morale. prevent joint stiffness.

strengthen the muscles while keeping the joints stationary. Explanation: An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process. Isometric exercise do not require specialized equipment, but this does not explain the benefits of the exercises. Isometric exercises may help improve a client's morale by promoting self-care, but this is not the reason for doing them. Because the joint is kept stationary, isometric exercise will not help prevent joint stiffness.

A client has had a radical neck dissection for laryngeal cancer. Which action is the priority for nursing care immediately following this surgery? maintaining complete bed rest until postsurgical swelling decreases taking vital signs once a shift until the client is stable determining if the client can swallow suctioning the laryngectomy tube as often as needed

suctioning the laryngectomy tube as often as needed Explanation: The nurse must maintain patency of the airway with frequent suctioning of the laryngectomy tube that can become occluded from secretions, blood, and mucus plugs. Once the client is hemodynamically stable, getting out of bed should be encouraged to prevent postoperative complications. Vital signs should be monitored more frequently in a postoperative client. A swallow study is done at approximately 5 to 7 days after surgery, prior to starting oral intake.

Which is not a typical clinical manifestation of multiple sclerosis (MS)? double vision sudden bursts of energy weakness in the extremities muscle tremors

sudden bursts of energy Explanation: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery? intermittent crying Logan bar in place swollen suture line suture line surrounded by erythema

suture line surrounded by erythema Explanation: There is a risk for infection in the suture line if it is not kept clean and dry. Signs of infection would include erythema or foul drainage from the suture line and fever. Crying intermittently is a normal assessment finding and the nurse should be prepared with liquids or formula. A suture line may be swollen in the immediate postoperative period, but its appearance will improve with time. A Logan bar may be used to hold the suture line in place

A nurse reviews the arterial blood gas (ABG) values of a client who reports difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases? complaints of constipation nausea and vomiting bradypnea tachypnea

tachypnea Explanation: Hyperventilation/tachypnea leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

Cushing's triad

three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation

The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that: a disease carrier also has the disease. two parents who are carriers may produce a child who has the disease. a disease carrier and an affected person will never have children with the disease. a disease carrier and an affected person will have a child with the disease.

two parents who are carriers may produce a child who has the disease. Explanation: Cystic fibrosis is the most common inherited disease in children. It is inherited as an autosomal recessive trait, meaning that the child inherits the defective gene from both parents. The chances are one in four for each of this couple's pregnancies.

The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the health care provider about? urinary output of 20 mL/hr over 2 hours temperature of 37.6°C (99.7°F) moderate amount of serous drainage on the surgical dressing blood pressure of 100/70 mm Hg

urinary output of 20 mL/hr over 2 hours Explanation: Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the health care provider. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? a core body temperature of 97.9° F (36.6° C) confusion when listening to explanations of procedures client experiencing polydipsia urine output of 90 mL over the past 6 hours

urine output of 90 mL over the past 6 hours Explanation: Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.

Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? absence of infection in the wounds adequate vascularization in the grafted area immobilization of the area being grafted use of analgesics as necessary for pain relief

use of analgesics as necessary for pain relief Explanation: Analgesic administration to keep a burn victim comfortable is important but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immobilization of the grafted area promote an effective graft.

Following an eclamptic seizure, the nurse should assess the client for which complication? polyuria facial flushing hypotension uterine contractions

uterine contractions Explanation: After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.

The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which indications of infection should the nurse detect during this stage? whitish yellow patches in the mouth dyspnea bloody diarrhea raised, hyperpigmented lesions on the legs

whitish yellow patches in the mouth Explanation: Oropharyngeal candidiasis, or thrush, is the most common infection associated with the early symptomatic stages of HIV infection. Thrush is characterized by whitish yellow patches in the mouth. Various other opportunistic diseases can occur in clients with HIV infection, but they tend to occur later, after the diagnosis of acquired immunodeficiency syndrome has been made. Dyspnea can be indicative of pneumonia, which is caused by a variety of infective organisms. Bloody diarrhea is indicative of cytomegalovirus infection. Hyperpigmented lesions are indicators of Kaposi's sarcoma.

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions? with the fingers of one hand with two fingertips with the palm of one hand with the heel of one hand

with the heel of one hand Explanation: When performing CPR on a child between ages 1 and 8, the nurse should use the heel of one hand to compress the chest one-third to one-half the depth of the chest. Using only the fingers of one hand isn't appropriate for CPR. The use of two fingertips is appropriate for infant CPR but this method can't compress the chest sufficiently on an older child. The palm is never used for chest compressions in CPR.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should: insert an oral airway. withhold food and fluids. position the client on his side. introduce a nasogastric (NG) tube.

withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals worsening dyspnea. gastric distention. nausea and vomiting. a temperature of 102° F (38.9° C).

worsening dyspnea. Explanation: Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.