Physiological Adaptation (#2)

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? You Selected: Improved muscle strength after I.V. administration of edrophonium chloride. Correct response: 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. Add a Note Question 2 See full question 23s A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? You Selected: Clay-colored stools Correct response: 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. Add a Note Question 3 See full question 28s A physician prescribes 150 mg of ibuprofen for a toddler whose temperature did not decrease after receiving acetaminophen. The oral suspension available contains 100 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using one decimal place. Your Response: 7.5 Correct response: 7.5 Explanation: To perform this calculation, set up the following equation: 150 mg/X = 100 mg/5 mL X = 7.5 mL. Add a Note Question 4 See full question 57s A client has 4000 mL removed via paracentesis. When the nurse weighs the client after the procedure, how many kilograms is an expected weight loss? Record you answer in whole numbers. Your Response: 4 Correct response: 4 Explanation: A liter of water weighs one kilogram. Therefore, the client should have a weight of 4 kilograms less than preprocedure weight. Add a Note Question 5 See full question 23s 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? You Selected: red, warm, palpable linear cord along the vein that is painful on palpation Correct response: 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 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is: You Selected: antibiotic therapy. Correct response: antibiotic therapy. Explanation: A child who has had rheumatic fever is likely to develop the illness again after a future streptococcal infection. Therefore, it is advised that the child receive antibiotic prophylaxis for at least 5 years and sometimes even longer after the acute attack to prevent recurrence. Add a Note Question 2 See full question 19s 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? You Selected: With the leg on the affected side abducted Correct response: 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. Add a Note Question 3 See full question 18s Following an eclamptic seizure, the nurse should assess the client for which complication? You Selected: uterine contractions Correct response: 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. Add a Note Question 4 See full question 39s The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? You Selected: Metabolic acidosis Correct response: Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Add a Note Question 5 See full question 24s After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention? You Selected: Perform a bladder scan, and obtain an order for urinary catheterization. Correct response: Perform a bladder scan, and obtain an order for urinary catheterization. Explanation: The client has overflow retention. A catheter relieves the discomfort by draining urine from the bladder. Permitting further distension could injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the primary cause. Nurses' self regulation practice can perform a bladder scan without an order. Other answers are incorrect because the client may have neurologic impairment and decreased sensation for voiding.

6 to 7

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? You Selected: measuring the infant's weight Correct response: measuring the infant's weight Explanation: Frequent weight measurement provides the most important information about fluid balance and the infant's response to fluid replacement. Although stool or urine analysis may provide some information, the results typically aren't available immediately, making the tests less useful than measuring weight. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant. Add a Note Question 2 See full question 57s When assessing a child with juvenile hypothyroidism, the nurse expects which finding? You Selected: goiter Correct response: goiter Explanation: Juvenile hypothyroidism results in goiter, weight gain, sleepiness, and a slow heart rate. It doesn't cause weight loss, insomnia, or tachycardia. Add a Note Question 3 See full question 57s A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? You Selected: "Before you do the exercise, I'll give you pain medication if you need it." Correct response: "Before you do the exercise, I'll give you pain medication if you need it." Explanation: The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour. Add a Note Question 4 See full question 1m 52s The surgical floor receives a client from the postanesthesia care unit. Ten minutes ago, the final assessment in the postanesthesia care unit indicated that the client had a patent airway and stable vital signs. The client's pain level was 2. What should the nurse do next? You Selected: Check the dressing for signs of bleeding. Correct response: Check the dressing for signs of bleeding. Explanation: The nurse should check the dressing for signs of bleeding to establish a baseline for future assessments of the dressing and to verify that there is no obvious sign of hemorrhage. The nurse does not need to empty peri-incisional drains at this time. All drains should have been emptied and reconstituted by the postanesthesia care nurse before the client was transferred to the surgical floor. Assessing the client's pain level and assessing the bladder are important; however, it is more important to assess the surgical site for bleeding because hemorrhage is a life-threatening complication of any surgical procedure. Add a Note Question 5 See full question 31s Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy? You Selected: "We need to make sure that her ear infection has completely cleared." Correct response: "We need to make sure that her ear infection has completely cleared." Explanation: Because ear infections are sometimes difficult to treat, determining if the antibiotic has resolved the infection is essential. If the child is not rechecked, it will be difficult to determine if another infection is a continuation of a previous infection or a separate, new infection. Although studies may be done to determine if an infection has impaired the child's hearing, they are not done routinely after each course of antibiotic therapy. A visit to the primary care provider's office cannot validate that all the medication was taken. A follow-up visit helps to determine if the infection has completely cleared. If the infection is resolved with one course of antibiotics, another course would not be prescribed. A child with lead poisoning is admitted to the facility for chelation therapy. The nurse must stay alert for which adverse effect of chelation therapy? You Selected: seizures Correct response: seizures Explanation: Chelation therapy removes lead by combining it with another substance to form a soluble compound that the kidneys can excrete. The nurse should stay alert for seizures because as lead is mobilized from bone and other tissues, the serum lead level rises rapidly, increasing the client's risk of seizures. Chelation therapy doesn't cause anaphylaxis, fever, chills, or heart failure. Add a Note Question 2 See full question 2m 9s The nurse should conduct a focused assessment for the client with suspected bladder cancer for which common sign of the disease? You Selected: painless hematuria Correct response: 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. Add a Note Question 3 See full question 18s Which respiratory pattern indicates increasing intracranial pressure in the brain stem? You Selected: slow, irregular respirations Correct response: 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. Add a Note Question 4 See full question 18s A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L (2.9 mmol/L), and arterial blood gas—pH 7.46, PCO2 45 mm Hg (6.0 kPA), PO2 95 mm Hg (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L). The nurse should implement which prescription first? You Selected: 5% Dextrose in 0.45% normal saline with KCl 40 mEq/L at 125 mL/h Correct response: 5% Dextrose in 0.45% normal saline with KCl 40 mEq/L at 125 mL/h Explanation: The vital signs suggest that the client is dehydrated from the vomiting, and the nurse should first infuse the IV fluids with the addition of potassium. There is no indication that the client needs oxygen at this time since the PO2 is 95 mm Hg (12.6 kPa). Although the client has a rapid and irregular pulse, the infusion of fluids may cause the heart rate to return to normal, and the 12-lead ECG can be prescribed after starting the intravenous fluids. Add a Note Question 5 See full question 20s A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? You Selected: The lump is round and movable. Correct response: The lump is round and movable. Explanation: When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm and non-movable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

7 to 8

Which intervention should a nurse use when administering oxygen by face mask to a client? You Selected: Assist the client to the semi-Fowler's position if possible. Correct response: Assist the client to the semi-Fowler's position if possible. Explanation: By assisting the client to the semi-Fowler's position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could cause irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should ensure that the connectors between the oxygen equipment and humidifier are airtight; loosened connectors can cause loss of oxygen. Add a Note Question 2 See full question 34s A client who has been treated for chronic open-angle glaucoma for 5 years asks the nurse, "How does glaucoma damage my eyesight?" What should the nurse tell the client? "Your glaucoma: You Selected: causes increased intraocular pressure." Correct response: causes increased intraocular pressure." Explanation: In COAG, there is an obstruction to the outflow of aqueous humor, leading to increased intraocular pressure. The increased intraocular pressure eventually causes destruction of the retina's nerve fibers. This nerve destruction causes painless vision loss. The exact cause of glaucoma is unknown. Glaucoma does not lead to retinal detachment. Add a Note Question 3 See full question 17s A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? You Selected: An irregular apical pulse Correct response: An irregular apical pulse Explanation: Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome. Add a Note Question 4 See full question 1m 31s 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? You Selected: Evaluate the tube for patency. Correct response: 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. Add a Note Question 5 See full question 1m 29s The nurse is preparing to discharge a 9-month-old infant recovering from gastroenteritis and dehydration and teaching a parent regarding the infant's dietary and fluid requirements. Which of the following statements made by the parent indicates that further instruction is required? You Selected: "We can go ahead and begin to the feed the baby whatever they want to eat and drink." Correct response: "We can go ahead and begin to the feed the baby whatever they want to eat and drink." Explanation: The baby will not be able to indicate when hungry or thirsty initially since appetite may be inhibited after the dehydration and could lead to further dehydration. It is appropriate for the parents to bring the child back if further diarrhea occurs. A lactose-free formula may be considered if the diarrhea continues and is unrelated to the gastroenteritis. Which description about crackles are true? You Selected: They may be fine or coarse. Correct response: 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. Add a Note Question 2 See full question 1m 26s Which is an initial sign of Parkinson's disease? You Selected: rigidity Correct response: tremor Explanation: The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia. Add a Note Question 3 See full question 1m 42s A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include: You Selected: inability to perform active movement and pain with passive movement. Correct response: inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor. Add a Note Question 4 See full question 1m 8s Which of the following would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube? You Selected: Auscultation indicates bowel sounds in all four quadrants. Correct response: Auscultation indicates bowel sounds in all four quadrants. Explanation: Auscultation of bowel sounds indicates that the bowel is recuperating from the effects of surgery and anesthesia. Peristalsis is returning, and if it progresses, the next step will be passing of gas. The results of palpation, percussion, and inspection do not give definitive information regarding peristalsis return. Add a Note Question 5 See full question 2m 10s A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? You Selected: pericardial tamponade Correct response: pericardial tamponade Explanation: A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (a pulse amplitude alteration from beat to beat, with a regular rhythm). Aortic regurgitation may cause a bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

LvL2to3

When a nurse assesses a client with suspected dehydration, which condition should be reported to the physician immediately? You Selected: decreased blood pressure Correct response: decreased blood pressure Explanation: The nurse should immediately report decreased blood pressure because it's a late sign of severe dehydration. This delayed decrease occurs because compensatory mechanisms in children are able to sustain blood pressure in the low-normal range for some time. Irritability, capillary refill less than 2 seconds, tachycardia, dry skin, and dry mucous membranes are all early signs of dehydration. Add a Note Question 2 See full question 37s What would be the most important nursing intervention in caring for the client's residual limb during the first 24 hours after amputation of the left leg? You Selected: Elevate the residual limb on a pillow. Correct response: Elevate the residual limb on a pillow. Explanation: Elevating the residual limb on a pillow for the first 24 hours after surgery helps prevent edema and promotes comfort by increasing venous return. Elevating the residual limb for longer than the first 24 hours is contraindicated because of the potential for developing a hip flexion contracture. Keeping the limb flat will be an important intervention after the first 24 hours. Preventing excessive swelling, however, is a priority in the first 24 hours. Adducting the residual limb on a scheduled basis prevents abduction contracture. Traction may be used to prevent or treat a hip flexion contracture—however, not in the first 24 hours. Add a Note Question 3 See full question 49s A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is: You Selected: a decrease in the blood flow through the kidneys." Correct response: a decrease in the blood flow through the kidneys." Explanation: There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents. Add a Note Question 4 See full question 1m 11s A client has the following arterial blood gas results: pH 7.32; PaCO2 50; HCO3 23; SaO2 80%. The nurse would interpret the arterial blood gases to be which of the following? You Selected: Respiratory acidosis Correct response: Respiratory acidosis Explanation: Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect. Add a Note Question 5 See full question 1m 3s The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note? You Selected: C Correct response: C Explanation: Epispadias is characterized by the urethral opening at the top (dorsal) aspect of the penis. Though the child will be able to urinate, surgical repair will be completed. Option A is the normal opening of the urethra at the tip of the penis. Option B documents hypospadias with the urethral opening at the underside (ventral) aspect of the penis. During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate? You Selected: Notify the health care provider (HCP) immediately. Correct response: Notify the health care provider (HCP) immediately. Explanation: A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the HCP immediately. The HCP should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise. Add a Note Question 2 See full question 40s A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? You Selected: Sweating, tremors, and tachycardia Correct response: Sweating, tremors, and tachycardia Explanation: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus. Add a Note Question 3 See full question 19s A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status, the nurse should review the results of which test? You Selected: albumin level Correct response: albumin level Explanation: Serum albumin levels help determine whether protein intake is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake. Add a Note Question 4 See full question 20s A 2-year-old is brought to the emergency department following a seizure. The child currently has the flu and has had fevers for the last 3 days. The father asks what caused the seizure. The nurse's best response is: You Selected: "The seizure likely occurred because your child's temperature rose beyond a personal threshold." Correct response: "The seizure likely occurred because your child's temperature rose beyond a personal threshold." Explanation: Febrile seizures usually occur during the rise in temperature and are related to the peak of the temperature rather than the rapidity or duration of elevation. When children experience febrile seizures, fevers usually exceed 38.0° C (100.4° F). Febrile seizures are not related to the rapidity or duration of elevation. Febrile seizures are most common among children 18 months to 3 years but are not related to the maturity of their immune system. Add a Note Question 5 See full question 18s 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? You Selected: The child has signs that the appendix has ruptured. Correct response: 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. Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do? You Selected: Rewarm the neonate gradually. Correct response: Rewarm the neonate gradually. Explanation: A neonate with a temperature of 94.1°F(34.5°C) is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Bathing the baby will further cause the baby to lose heat. Hourly observation is not frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the health care provider of the problem as soon as it is identified. Add a Note Question 2 See full question 29s A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? You Selected: Blood supply to the stoma has been interrupted. Correct response: Blood supply to the stoma has been interrupted. Explanation: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color. Add a Note Question 3 See full question 47s A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? You Selected: Elevating the stump for the first 24 hours Correct response: Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery. Add a Note Question 4 See full question 27s 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? You Selected: "Return immediately if acute flank or mid-abdominal pain occurs." Correct response: "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. Add a Note Question 5 See full question 29s A female client who is 32 years of age has been diagnosed with stage 1 hypertension. The client's height is 5 feet 5 inches (165 cm), and her weight is recorded as 125 pounds (56.6 kg); she reports that she frequently eats at "fast food" restaurants and enjoys a glass of wine to relax on weekends. In developing a teaching plan for this client, the nurse should address which topic? You Selected: low-sodium food choices Correct response: low-sodium food choices Explanation: Lifestyle modification to lower blood pressure includes weight reduction in clients who are overweight, reducing the intake of dietary sodium, and an increase in physical activity. Client teaching involves instruction on low sodium diet and foods because of the propensity for high-sodium foods at fast food restaurants. The client is of a normal weight, and alcohol intake is in moderation. Nitroprusside is a treatment for hypertensive crisis. Which is the priority intervention for a preschool child with epiglottiditis and a deteriorating respiratory status? You Selected: assisting with intubation Correct response: assisting with intubation Explanation: The most important intervention for a child with epiglottiditis is airway management because children are at high risk for developing abrupt airway obstruction. Therefore, intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they will never allow a mask to stay in place. Provide humidified "blow-by" oxygen administered by the parent if possible. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management. Add a Note Question 2 See full question 1m 21s Which would be the most appropriate measure for preventing the development of a paralytic ileus in a client who had renal surgery yesterday? Correct response: Encourage the client to ambulate every 2 to 4 hours. Explanation: Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-mouth status until peristalsis returns. Carbonated beverages will increase gas and distention but will not stimulate peristalsis. A stool softener will not stimulate peristalsis. IV fluid infusion is a routine postoperative prescription that does not have any effect on preventing paralytic ileus. Add a Note Question 3 See full question 32s Which behavior by a neonate attempting an initial feeding should indicate to the nurse that the neonate may have tracheoesophageal fistula? You Selected: coughing, choking, and cyanosis that occur after several swallows of formula Correct response: coughing, choking, and cyanosis that occur after several swallows of formula Explanation: The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth. Poor rooting reflexes and sucking attempts are typical of infants with neurologic dysfunction or related to reflex depression secondary to medication given to the mother during labor. Projectile vomiting is typical of infants with neurologic dysfunctions. This reflex may also be depressed by medication given to the mother during labor. Falling asleep after taking little formula is characteristic of an infant who becomes exhausted with the exertion of feeding, commonly caused by a cardiac anomaly. Add a Note Question 4 See full question 14s A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? Correct response: Lactated Ringer's solution Explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental. Add a Note Question 5 See full question 35s A 22-year-old client reports substernal chest pain and states that his/her heart feels like "it's racing out of my chest." The client reports no history of cardiac disorders. The nurse attaches him/her to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear, and the respiratory rate is 26 breaths/minute. When a cardiorespiratory basis is eliminated, which drug would the nurse question about usage? You Selected: cocaine Correct response: cocaine Explanation: Because of the client's age and negative medical history, the nurse would question about cocaine use. Barbiturate overdose may trigger respiratory depression and a slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and MI.

LvL 1 to 2

A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal? You Selected: Maintaining effective respirations Correct response: Maintaining effective respirations Explanation: As suggested by the ABCs of cardiopulmonary resuscitation — airway, breathing, and circulation — the most important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation. Although maintaining an adequate circulatory volume, reducing anxiety, and relieving pain are pertinent for this client, they're secondary to maintaining effective respirations. Add a Note Question 2 See full question 1m 29s Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? You Selected: bulging fontanels Correct response: bulging fontanels Explanation: A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe. Add a Note Question 3 See full question 51s Which is the most accurate method of determining the extent of a client's fluid loss? You Selected: weighing the client Correct response: weighing the client Explanation: Accurate daily weight measurement provides the best measure of a client's fluid status: 1 kg (2.2 lb) is equal to 1,000 mL of fluid. To be accurate, weight should be obtained at the same time every day, with the same scale, and with minimal clothing on. Add a Note Question 4 See full question 31s A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol, 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located? You Selected: Heart Correct response: Heart Explanation: Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi. Add a Note Question 5 See full question 15s After being admitted to the emergency department for severe lower right quadrant pain, a child states that the pain has suddenly resolved. Which of the following would the nurse suspect? You Selected: Ruptured appendix Correct response: Ruptured appendix Explanation: When a client with severe right lower quadrant pain has a sudden relief of pain, a ruptured appendix should be suspected. Although gastroenteritis, celiac disease, and food allergies may elicit a pain response, the specific presentation of right lower quadrant sudden pain is indicative of a ruptured appendix. Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should: You Selected: tell the children not to bite their fingernails. Correct response: tell the children not to bite their fingernails. Explanation: Pinworms come out of the intestine through the anus at night to lay eggs, causing perianal itching. The child wakes up and may begin scratching. Eggs under the fingernails are carried to the mouth if the child chews on the fingernails, and the life cycle of the pinworm continues. In addition to teaching children not to bite their fingernails, parents should keep the nails short and encourage hand washing before food preparation and eating. Sharing hairbrushes contributes to the spread of head lice, not pinworms. Although covering the mouth and nose are hygienic practices to reduce the spread of infections from respiratory droplets, doing so doesn't affect the spread of pinworms. There are no immunizations to protect against pinworms. Add a Note Question 2 See full question 23s Which characteristic would make the nurse suspect that a client with changes in cognition has delirium? You Selected: disturbances in cognition and consciousness that fluctuate during the day Correct response: disturbances in cognition and consciousness that fluctuate during the day Explanation: In addition to developing over a period of hours or days, fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia. Add a Note Question 3 See full question 32s What would be the most important nursing intervention in caring for the client's residual limb during the first 24 hours after amputation of the left leg? You Selected: Elevate the residual limb on a pillow. Correct response: Elevate the residual limb on a pillow. Explanation: Elevating the residual limb on a pillow for the first 24 hours after surgery helps prevent edema and promotes comfort by increasing venous return. Elevating the residual limb for longer than the first 24 hours is contraindicated because of the potential for developing a hip flexion contracture. Keeping the limb flat will be an important intervention after the first 24 hours. Preventing excessive swelling, however, is a priority in the first 24 hours. Adducting the residual limb on a scheduled basis prevents abduction contracture. Traction may be used to prevent or treat a hip flexion contracture—however, not in the first 24 hours. Add a Note Question 4 See full question 37s A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? You Selected: Hemiplegia, seizures, and decreased level of consciousness (LOC) Correct response: Hemiplegia, seizures, and decreased level of consciousness (LOC) Explanation: Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage. Add a Note Question 5 See full question 1m 1s A physician prescribes 150 mg of ibuprofen for a toddler whose temperature did not decrease after receiving acetaminophen. The oral suspension available contains 100 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using one decimal place. Correct response: 7.5 Explanation: To perform this calculation, set up the following equation: 150 mg/X = 100 mg/5 mL X = 7.5 mL.

LvL 3 to 4

After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which problem? You Selected: hydrocephalic infant Correct response: hydrocephalic infant Explanation: Congenital anomalies such as hydrocephalus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth restriction, and poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of severe vasoconstriction. Intrauterine growth restriction is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction. Add a Note Question 2 See full question 30s The mother of a preschool child with juvenile idiopathic arthritis (JIA) is worried that her child will have to stop attending preschool because of the illness. Which response by the nurse would be most appropriate? You Selected: "Your child should be encouraged to attend school, but he will need extra time to work out early morning stiffness." Correct response: "Your child should be encouraged to attend school, but he will need extra time to work out early morning stiffness." Explanation: Socialization is important for this preschool-age child, and activity is important to maintain function. Because children with JIA commonly experience most problems in the early morning after arising, they need more time to "warm up." Adverse effects may or may not occur. The child's normal routine needs to be maintained as much as possible. Although splints and braces may be needed, they are worn during periods of rest, not activity, to maintain function. Add a Note Question 3 See full question 33s A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. What should the nurse assess the client for after surgery? You Selected: respiratory paralysis Correct response: respiratory paralysis Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia. Add a Note Question 4 See full question 16s In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? You Selected: Decreased level of consciousness (LOC) Correct response: Increased restlessness Explanation: In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress. Add a Note Question 5 See full question 29s A client at 24 weeks gestation comes to the clinic for a prenatal check-up and informs the nurse that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem? You Selected: Gestation hypertension Correct response: Gestation hypertension Explanation: A client with gestational hypertension typically presents with headaches, double vision, and sudden weight gain. Additional findings include proteinuria. Clients with gestational diabetes would have elevated glucose levels. The client with hyperemesis gravidarum would present with intractable vomiting and signs of dehydration. Placenta previa is the covering of the cervical os with the placenta and would be demonstrated by painless vaginal bleeding. Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? You Selected: Provide warm, humidified oxygen in a warm environment. Correct response: Provide warm, humidified oxygen in a warm environment. Explanation: Symptoms of transient tachypnea include respirations as high as 150 breaths/minute, retractions, flaring, and cyanosis. Treatment is supportive and includes provision of warm, humidified oxygen in a warm environment. The nurse should continuously monitor the neonate's respirations, color, and behaviors to allow for early detection and prompt intervention should problems arise. Feedings are given by gavage rather than bottle to decrease respiratory stress. Obtaining extracorporeal membrane oxygenation equipment is not necessary but may be used for the neonate diagnosed with meconium aspiration syndrome. Add a Note Question 2 See full question 42s Which is a priority focus of care for a client experiencing an exacerbation of Crohn's disease? You Selected: promoting bowel rest Correct response: promoting bowel rest Explanation: A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected. Add a Note Question 3 See full question 28s A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? You Selected: The client had a liver transplant 2 years ago. Correct response: The client had a liver transplant 2 years ago. Explanation: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized. Add a Note Question 4 See full question 3m 11s A client has been pronounced brain dead. Which findings should the nurse document? Select all that apply. You Selected: deep tendon reflexes nonreactive dilated pupils absent corneal reflex Correct response: nonreactive dilated pupils deep tendon reflexes absent corneal reflex Explanation: A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes, such as deep tendon and Babinski reflexes, in brain death. Decerebrate or decorticate posturing would not be observed in this client. Clients who are brain dead do not have a blink reflex. Add a Note Question 5 See full question 38s 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? You Selected: Insert a peripheral intravenous fluid line and infuse normal saline. Correct response: 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.

LvL 4 to 5