Physiological Adaptation

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 client action would indicate to the nurse that the teaching was successful? A. The client trims the faceplate opening giving the stoma a 1-inch (2.5 cm) border around the stoma. B. The client assesses the stoma and the surrounding skin before placing the new appliance. C. The client chooses an antibacterial soap to scrub the fecal material around the stoma. D. The client states that the faceplate should be changed every other day.

B. The client assesses the stoma and the surrounding skin before placing the new appliance..

Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. A. respirations at 26 breaths/min, circumoral cyanosis present, orthopneic B. anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min C. disoriented; oxygen saturation levels at 85%; coughing large amount thick, white sputum; dyspnea on exertion D. edema of the extremities, labored respirations, color normal E. lung sounds clear bilaterally with non-labored respirations noted

B. anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min & E. lung sounds clear bilaterally with non-labored respirations noted

A client with a progressively enlarging neck comes into the clinic. The client mentions that they have been in a foreign country for the previous 3 months and that they didn't eat much while there because they didn't like the food. The client also mentions that they become dizzy when lifting their arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose? A. diabetes mellitus B. goiter C. diabetes insipidus D. Cushing's syndrome

B. goiter

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the... A. stomach. B. small intestine. C. large intestine. D. rectum.

B. small intestine.

A client is diagnosed with hypothyroidism. What additional information should the nurse obtain when conducting a focused assessment? A. tachycardia B. weight gain C. diarrhea D. nausea

B. weight gain

While caring for a female term neonate just born, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? A. renal disorders B. Potter syndrome C. ambiguous genitalia D. Turner syndrome

C. ambiguous genitalia

The nurse teaches the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly. The nurse determines that the teaching was successful when the parent describes the condition in which way? A. "The muscle below the stomach is too tight, causing the baby to vomit forcefully." B. "There is a blind upper pouch and an opening from the esophagus into the airway." C. "The lower bowel is lacking certain nerves to allow normal function." D. "A part of the bowel is on the outside without anything covering it."

B. "There is a blind upper pouch and an opening from the esophagus into the airway."

The nurse is instructing a group of parents on nutritional problems that can occur in toddlers. When teaching the parents how to assess a child for iron deficiency anemia, which of the following is the most important information for the nurse to share? A. Monitor the child for excess irritability. B. Check the child's pulse for a slow heart rate. C. Look for a white coating on the child's tongue. D. Assess the child's skin for the appearance of bruising.

A. Monitor the child for excess irritability.

The nurse administers lisinopril to a client. What assessment findings does the nurse document as evidence of a positive therapeutic response? A. blood pressure 118/74 mmHg B. apical heart rate 88 bpm C. potassium level 4.0 mEq/L (mmol/L) D. total cholesterol level of 200 mg/dL (5.2 mmol/L)

A. blood pressure 118/74 mmHg

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which symptom? A. heartburn B. jaundice C. anorexia D. stomatitis

A. heartburn

Which client is at risk for pulmonary embolism? A client with: A. arteriosclerosis. B. a small abdominal aneurysm. C. deep vein thrombosis (DVT). D. varicose veins.

C. deep vein thrombosis (DVT).

While transferring a load of firewood from the front driveway to the backyard woodpile at 11 a.m., the client experienced a heaviness in the chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 12:30 p.m., the client's spouse took the client to the emergency department. Around 1:30 p.m., the health care provider diagnosed an anterior myocardial infarction (MI). The nurse should anticipate which orders by the health care provider? A. streptokinase, aspirin, and morphine administration B. morphine administration, stress testing, and admission to the cardiac care unit C. serial liver enzyme testing, telemetry, and a lidocaine infusion D. sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry

D. sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry

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? A. Encourage the client to drink at least 1,000 mL/day. B. Provide parenteral rehydration therapy as prescribed. C. Turn and reposition every 2 hours. D. Monitor vital signs every shift.

B. Provide parenteral rehydration therapy as prescribed.

The parent of a preschool child with juvenile idiopathic arthritis (JIA) is worried that their child will have to stop attending preschool because of the illness. Which response by the nurse would be most appropriate? A. "It may be difficult for your child to attend school because of the side effects of the medications they will be prescribed." B. "Your child should be encouraged to attend school, but they will need extra time to work out early morning stiffness." C. "You should keep your child at home from school whenever they experience discomfort or pain in their joints." D. "Your child will probably need to wear splints and braces so that their joints will be supported properly."

B. "Your child should be encouraged to attend school, but they will need extra time to work out early morning stiffness."

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? A. Indwelling urinary catheter kit B. Tracheostomy set C. Cardiac monitor D. Humidifier

B. Tracheostomy set

A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? A. "You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders." B. "You will not feel the local anesthetic being applied because it will be sprayed on." C. "You will feel a pulling type of discomfort for a few seconds." D. "After the needle is removed, you will feel a bandage being applied around your chest."

C. "You will feel a pulling type of discomfort for a few seconds."

The nurse at the clinic is assessing a toddler and notices retractions while the child is breathing. The parents state that they began to notice the retractions a few days ago and wondered if it was significant. What is the best response by the nurse? A. "Retractions occur normally when children are very active." B. "This is very serious; you should have brought your child in sooner." C. "Your child is having difficulty breathing and we need to determine why." D. "This is an indication that your child has a respiratory infection."

C. "Your child is having difficulty breathing and we need to determine why."

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? A. 16 breaths/min and deep in character B. 18 breaths/min and inhaled through the mouth C. 20 breaths/min and shallow in character D. 28 breaths/min and audible

D. 28 breaths/min and audible

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan? A. imbalanced nutrition: less than body requirements related to inadequate feeding B. hypothermia related to immature temperature regulation C. deficient fluid volume related to insensible fluid loss D. risk for injury related to hyperbilirubinemia

D. risk for injury related to hyperbilirubinemia