PP Q's

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Encourage coughing and deep breathing. Position the client with the head turned toward the side of the brain tumor. Administer stool softeners. Provide sensory stimulation.

Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

The nurse is caring for a client in the first stage of labor who states, "I am scared. The last time I gave birth, I was in labor for 32 hours, it was awful." What is the nurse's best response? "Let me call the anesthesiologist and get you an epidural right away." "Let's talk about options that can keep you more comfortable this time." "Your second labor should be much shorter." "Maybe we can start some oxytocin to speed things up."

"Let's talk about options that can keep you more comfortable this time." Explanation: A client's ability to cope during labor and childbirth may be hampered by fear of a long, painful or difficult childbirth. A previous negative experience may increase these fears. The client's anxiety stems from her past history of a long labor. Engaging the client in planning options will give more control and let her know that the nurse will support her through this labor. An immediate epidural may lengthen labor time, the nurse cannot know that labor will be shorter. Oxytocin is not an appropriate option at this time.

Which client has the highest risk of ovarian cancer? 30-year-old woman taking hormonal contraceptives 36-year-old woman who had her first child at age 22 40-year-old woman with three children 45-year-old woman who has never been pregnant

45-year-old woman who has never been pregnant Explanation: The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? Establish intravenous access. Administer epinephrine. Administer albuterol (salbutamol). Provide respiratory support with bag-valve mask.

Administer epinephrine. Explanation: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent adrenergic agonist, as ordered. The healthcare provider is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. The nurse should continue to monitor the client's vital signs; a client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring. However, administering epinephrine is the first priority.

A nurse is monitoring a full-term laboring client on oxytocin. What interventions would be priorities for the nurse if the client experiences late decelerations? Select all that apply. Give oxygen. Report the findings to the heath care professional (HCP). Perform a vaginal examination for prolapsed cord. Position the client on her left side. Stop the infusion of oxytocin.

Give oxygen. Report the findings to the heath care professional (HCP). Position the client on her left side. Stop the infusion of oxytocin. Explanation: The presence of late decelerations indicates that the fetus is affected by placental insufficiency. There is decreased blood flow and oxygen available during the contraction when the uterine blood vessels are compressed during a contraction. Interventions to increase placental perfusion include positioning the client on her left side and stopping the infusion of oxytocin. Giving oxygen will reduce fetal hypoxia. Decelerations also need to be reported to the HCP immediately. Prolonged decelerations indicate cord compression. A vaginal exam would not be a priority at this time.

Which should be included in the client's plan of care during dialysis therapy? Limit the client's visitors. Monitor the client's blood pressure. Pad the side rails of the bed. Keep the client on nothing-by-mouth (NPO) status.

Monitor the client's blood pressure. Explanation: Because hypotension is a complication associated with peritoneal dialysis, the nurse records intake and output, monitors vital signs, and observes the client's behavior. The nurse also encourages visiting and other diversional activities. A client on peritoneal dialysis does not need to be placed in a bed with padded side rails or kept on NPO status.

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Blood pressure of 120/64 to 130/72 mm Hg Sodium level of [142 mEq/L (142 mmol/L)]

Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Explanation: Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings.

After an amniotomy, which client goal should take the highest priority? The client will express increased knowledge about amniotomy. The client will maintain adequate fetal tissue perfusion. The client will display no signs of infection. The client will report relief of pain.

The client will maintain adequate fetal tissue perfusion. Explanation: Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

The nurse is assessing breath sounds of a child admitted to the unit. Based on the following progress notes, which respiratory illness would the nurse suspect? Progress notes10/152030Seven-year-old child admitted from ER. Oxygen via mask at 4 L/min. Frequent, tight cough. A/Ox3. Shortness of breath noted while talking to mom. HEENT normal. Lungs with wheezing in bases. Heart RRR, no murmur. Abdomen soft, flat. Active bowel sounds. Moving all extremities well. pneumonia croup pulmonary edema asthma

asthma Explanation: Asthma frequently presents with wheezing and coughing. Airway inflammation and edema increase mucous production. Other signs include dyspnea, tachycardia, and tachypnea. Stridor is heard in croup. Rhonchi and rales are heard with pneumonia and pulmonary edema.

A client, recovering from a spinal cord injury, has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity? hydralazine baclofen lidocaine methylprednisolone

baclofen Explanation: Baclofen is a skeletal muscle relaxant used to decrease spasms. It may be given orally or intrathecally. Hydralazine is an antihypertensive and afterload-reducing agent. Lidocaine is an antiarrhythmic and a local anesthetic agent. Methylprednisolone is an anti-inflammatory drug used to decrease spinal cord edema in the acute phase.

The nurse should teach clients about which potential risk factor for the development of colon cancer? chronic constipation long-term use of laxatives history of smoking history of inflammatory bowel disease

history of inflammatory bowel disease Explanation: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet.

Which nursing diagnosis would be the priority for a client who has just been admitted to the hospital with burns? body image disturbance risk for altered nutrition impaired social interaction impaired skin integrity

impaired skin integrity Explanation: Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection. While body image, social interaction, and altered nutrition are all concerns, they are not necessarily potentially life threatening, unlike the impaired skin integrity.

A nurse is caring for a client who had a prostatectomy for prostate cancer. The nurse is reviewing the client's vital signs and intake and output as documented by a nursing assistant. Which documented finding requires immediate action? blood pressure heart rate intake and output temperature

intake and output Explanation: The client has a significantly greater intake than output. This finding may indicate that the catheter is blocked and causing urine retention. The nurse should immediately irrigate the catheter and try to determine if clots are blocking the catheter. If the nurse is unable to irrigate the catheter, the healthcare provider should be notified immediately. The client's heart rate and blood pressure are normal. Although the temperature is slightly elevated, this finding is not a priority at this time.

A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcomes indicate that the client has adequate respiratory function? Select all that apply. respiratory rate of 12 to 20 breaths per minute use of accessory muscles with each breath breath sounds present and equal in all lobes oxygen saturation on room air is 95%. orthopneic breathing exhibited

respiratory rate of 12 to 20 breaths per minute breath sounds present and equal in all lobes oxygen saturation on room air is 95%. Explanation: A respiratory rate of 12 to 20 breaths/min is a normal finding, indicating adequate respiratory function. If the pneumothorax is not completely resolved, the client will not have breath sounds heard equally in the affected lobe(s). Normal oxygen saturation on room air is 95% to 100%. Orthopneic breathing and accessory muscle use indicate an interference with respiratory function.

A client in active labor asks the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse? "It is part of our standard policy." "Changes in your blood pressure can affect the fetus." "Low blood pressure may cause dizziness and fainting." "Increased blood pressure is a sign of preeclampsia."

"Changes in your blood pressure can affect the fetus." Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. Preeclampsia causes the blood pressure to increase, and low blood pressure may cause dizziness; however, neither fact explains the primary reason for frequent monitoring. Telling the client that it is policy is not a patient-centered response.

Which statement indicates that a new graduate nurse understands central venous pressure (CVP) measurement when used on a client? "The test accurately measures rate and rhythm of breathing patterns." "The test determines approximate blood pressure." "A high CVP leads to superior vena cava syndrome." "The test will assess pressure and volume changes in the right atrium."

"The test will assess pressure and volume changes in the right atrium." Explanation: The best rationale for CVP measurement is to assess pressure and volume in the right atrium. CVP does not measure breathing patterns or blood pressure. Superior vena cava syndrome is usually caused by an obstruction such as a tumor or lymphoma.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care? Test all stools for occult blood. Administer topical ointment to the rectal area to decrease bleeding. Prepare the client for a gastrostomy tube placement. Administer morphine routinely, as ordered.

Test all stools for occult blood. Explanation: Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed

In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: Enlarged, painless lymph nodes. Headache. Hyperplasia of the gums. Unintentional weight loss.

Unintentional weight loss. Explanation: Clients with CLL develop unintentional weight loss; fever and drenching night sweats; enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin sensitivity tests (anergy); and susceptibility to viral infections. Enlarged, painless lymph nodes are a clinical manifestation of Hodgkin's lymphoma. A headache would not be one of the early signs and symptoms expected in CLL because CLL does not cross the blood-brain barrier and would not irritate the meninges. Hyperplasia of the gums is a clinical manifestation of AML.

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? Use the unaffected arm for blood pressure measurements. Draw blood from the cannula for routine laboratory work. Percuss the cannula for bruits each shift. Inject heparin into the cannula each shift.

Use the unaffected arm for blood pressure measurements. Explanation: The unaffected arm should be used for blood pressure measurement. The external cannula must be handled carefully and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at the bedside because dislodgment of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood pressure measurement, IV therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be heparinized.

The nurse is conducting a health history for a client at risk for cancer. Which lifestyle factor is considered a risk for colorectal cancer? a diet low in vitamin C a high dietary intake of artificial sweeteners a high-fat, low-fiber diet multiple sex partners

a high-fat, low-fiber diet Explanation: A high-fat, low-fiber diet is a risk factor for colorectal cancer. A diet low in vitamin C, use of artificial sweeteners, and multiple sex partners are not considered risk factors for colorectal cancer.

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown in the accompanying image. Which finding is expected when assessing this client? (Photo shows injury below the umbilicus) inability to move his arms loss of sensation in his hands and fingers dysfunction of bowel and bladder difficulty breathing

dysfunction of bowel and bladder Explanation: This client has a spinal cord injury of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia.

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer? female nurse with 3 years' experience working in oncology male nurse who has floated to this unit from the operating room female nurse with 10 years' experience who suspects she may be pregnant male nurse who is also assigned to another client receiving brachytherapy

female nurse with 3 years' experience working in oncology Explanation: Brachytherapy is internal radiation and nurses must use the principles of time, distance, and shielding. Radiation has cumulative effects and the nurse already working with a client receiving radiation should not be exposed to additional radiation. Working with clients who are receiving internal radiation takes a certain skill set, and the male nurse who has floated from the operating room is not the best person to work with this client. Radiation is harmful to the fetus, and the nurse who suspects she is pregnant should not be exposed to radiation.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? hypercalcemia hyperkalemia hypernatremia hypermagnesemia

hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for chronic liver failure. acute heart failure. pathologic bone fractures. hypoxemia.

pathologic bone fractures. Explanation: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.

A client with suspected cervical cancer had a colposcopy with conization. What information should the nurse give the client about her menstrual periods after this surgery? Her periods will return to normal after 6 months. Her next two or three periods may be heavier and more prolonged than usual. Her next two or three periods will be lighter than normal. She may skip her next two periods.

Her next two or three periods may be heavier and more prolonged than usual. Explanation: The client should be informed that her next two or three periods could be heavy and prolonged. The client is instructed to report any excessive bleeding. The nurse should reinforce the necessity for the follow-up check and the review of the biopsy results with the client. The client's periods will not be normal for 2 to 3 months.

The nurse is teaching a group of parents about the risk of airway obstruction in young children. What information is most appropriate for the nurse to share regarding the risk of airway obstruction? "Sleeping with a blanket is safe for the child after the child can roll over on one's own." "A small airway makes it easier for foreign objects to cause obstruction." "A flat diaphragm makes it easier to expel objects obstructing the airway." "After the child starts school the risk for the child getting an obstruction decreases."

"A small airway makes it easier for foreign objects to cause obstruction." Explanation: A child's small airway increases the risk of airway obstruction from small foreign objects. Relatively small amounts of mucus, blood, or edema can lead to respiratory failure. Likewise, small amounts of swelling may result in a great reduction in airway diameter. The small child has a large tongue in a small mouth, which makes airway obstruction more common. The young child has a flat diaphragm, and this makes the lungs more compliant, which increases the difficulty of expelling an obstruction. The airway will not expand; it will constrict. Airway obstruction or suffocation increases when infants and toddlers sleep on soft surfaces and with blankets or stuffed animals in the crib, no matter their ability to turn over. Airway obstruction has the highest incidence in children under 4 due to their exploring the world, but it can happen at any age. No child is immune.

A client asks, "Can my partner and I still engage in sexual intercourse while I'm pregnant?" What should the nurse tell the client? "Throughout the pregnancy, coitus interruptus is the preferred method for sexual activity." "Although your sexual desire may change, intercourse is safe during an uncomplicated pregnancy." "You should avoid having intercourse until you are at least 16 weeks pregnant." "Refrain from having sexual intercourse when you are in the last trimester."

"Although your sexual desire may change, intercourse is safe during an uncomplicated pregnancy." Explanation: Generally, engaging in the usual pattern of sexual activity during pregnancy is safe as long as the client is comfortable and no complications arise. The client needs to be informed that some women find intercourse uncomfortable during the first and third trimesters, owing to the common discomforts of pregnancy.Numerous myths about engaging in sexual activity during pregnancy exist. However, coitus does not harm the fetus. Coitus interruptus is not considered the preferred method of sexual activity.Avoiding sexual activity until the 16th week of pregnancy is not necessary because coitus does not harm the fetus.During the third trimester, sexual intercourse is still considered safe. However, because of the increased size of the woman's abdomen, the couple should consider coital positions other than male superior position. Sexual intercourse would be contraindicated only if the woman experiences bleeding or ruptured membranes. Also, after 32 weeks' gestation, women with a history of preterm labor should be advised that coitus may lead to preterm labor due to the effects of prostaglandin production secondary to sexual intercourse. Stimulation of the breasts and nipples increases the body's production of oxytocin, which also can initiate labor.

A nurse is caring for a newborn with transient tachypnea of the newborn (TTN). Which responses made by the newborn's mother demonstrates that she understands the newborn's condition? Select all that apply. "Having a cesarean section increased the risk of transient tachypnea of my newborn." "My newborn is on oxygen because I was exposed to smoke during pregnancy." "I will need to give supplemental oxygen to my baby for the next 6 months." "The healthcare provider will need chest X-rays to monitor my baby's respiratory distress." "I can feed my newborn even though the respiratory rate is fast."

"Having a cesarean section increased the risk of transient tachypnea of my newborn." "The healthcare provider will need chest X-rays to monitor my baby's respiratory distress." Explanation: TTN is caused by retention of extra amniotic fluid in the lung fields. Newborns who are born by cesarean section are more likely to have TTN because the mechanical squeezing of the newborn's rib cage does not occur with birth. The most distinguishing feature of TTN is the lung fields on a chest X-ray where there is hyperaeration of the alveoli. TTN usually lasts 48-72 hours and newborns will need oxygen during this time period. TTN usually requires a low percentage of oxygenation (40% or less) along with supportive care such as IV fluid, antibiotics, and placement in a warmer. If the respiratory rate is consistently above 60 breaths/minute, the newborn takes nothing by mouth due to the risk of aspiration. Although smoking during pregnancy can lead to a smaller baby, smoking is not linked with TTN.

The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement? "I will have to pace my activities with rest periods." "I cannot wait to get home to my cat!" "I will use warm saline gargle instead of brushing my teeth." "I must report a temperature of 100° F (37.7 C)."

"I cannot wait to get home to my cat!" Explanation: The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's white blood cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods. Platelet production will be decreased, and the client will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of 100° F (37.8° C) or higher.

Which statement indicates that a client understands the need for routine screening to detect colorectal cancer? "I need to have a colonoscopy at age 45 then every 10 years until age 75." "I will submit a stool sample for occult blood at age 50 and then yearly until age 75." "I will have a flexible sigmoidoscopy at age 45 and then every 10 years until age 70." "I need to have a stool DNA test at age 50 and repeat every 3 years."

"I need to have a colonoscopy at age 45 then every 10 years until age 75." Explanation: The American Cancer Society (Canadian Cancer Society and Health Canada) recommends that starting at age 45 (not age 50), individuals of average risk undergo regular screening with one of six different tests and that screening happen through age 75. For clients at normal risk, colonoscopy should be repeated every 10 years, fecal occult blood test (FOBT) should be repeated every year, flexible sigmoidoscopy is recommended every 5 years (not every 10 years), and a stool DNA test is repeated every 3 years. The recommendations do not prioritize one test over another.

An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care? "I use a soft toothbrush to clean my teeth." "I remove white patches from my tongue and cheeks with my toothbrush." "I rinse my mouth every 2 to 4 hours with a solution of baking soda and water." "I don't use commercial mouthwashes."

"I remove white patches from my tongue and cheeks with my toothbrush." Explanation: White patches on the tongue and oral mucosa indicate infection; the adolescent should report the patches, not remove them. Using a soft toothbrush is appropriate because it prevents injury to the fragile oral mucosa. Rinsing the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution helps prevent stomatitis. Avoiding commercial mouthwashes is appropriate because they may contain alcohol, which may dry the oral mucosa.

When evaluating a pregnant client's knowledge of symptoms to report immediately, which statement indicates to the nurse that the client understands the information given to her? "I'll report increased frequency of urination." "If I have blurred or double vision, I should call the clinic immediately." "If I feel tired after resting, I should report it immediately." "Nausea should be reported immediately."

"If I have blurred or double vision, I should call the clinic immediately." Explanation: The client stating that she should contact the clinic if she experiences blurred or double vision indicates understanding of symptoms to report. Blurred or double vision may indicate hypertension or preeclampsia. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy. These symptoms don't need to be reported immediately.

A teen client, who is one week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which comment by the client would indicate that she understood the nurse's teaching about the postpartum period and her risks for postpartum depression? "Sleep shouldn't be too much of a problem, because the baby will soon start to sleep through the night." "Since I'm breastfeeding, I can eat all the food I want and not feel fat. The baby will use all the calories." "If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." "I'm going to give the baby the best care possible without asking anyone for help to show all those people who think I can't do it."

"If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." Explanation: Feelings of guilt combined with a lack of self-care (not eating or sleeping enough) can predispose a new mother to postpartum depression, especially one who has had previous episodes of depression. Sleep is essential to both the mother and baby, but sleeping through the night does not usually occur in the first few weeks after birth. While breastfeeding mothers do need good nutrition, unlimited eating after childbirth may inhibit the return to a normal weight and could create depression in a new mother, especially a vulnerable one. Attempting to care for an infant with no help from others is likely to cause stress that could lead to depression, especially in an adolescent.

A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. When discussing the potential impact of this procedure on the client's sexuality, how should the nurse respond to the client? "All women experience sexual problems with this surgical procedure. Do you have any questions?" "When can I schedule an appointment with you and your partner to discuss any issues either of you may have regarding sexuality?" "Do you anticipate any problems with sex related to your scheduled hysterectomy?" "Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"

"Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?" Explanation: This question introduces some basic information and allows for support for the client who may be experiencing some sexuality concerns. Not all women experience sexual problems after undergoing a hysterectomy. Assuming that the client will want to schedule an appointment with her partner is inappropriate and may embarrass her. Simply asking the client whether she expects to have problems with sex is too abrupt and does not provide any information.

A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor? "My child has grown 3" in the past 6 months." "My child seems to be napping for longer periods." "My child's abdomen seems bigger, and his diapers are much tighter." "My child's appetite has increased so much lately."

"My child's abdomen seems bigger, and his diapers are much tighter." Explanation: The most common presenting sign of a Wilms' tumor is abdominal swelling or an abdominal mass. Therefore, the mother's observation that her child's abdomen seems bigger suggests a Wilms' tumor. A rapid increase in length (height) isn't associated with this type of tumor. Although lethargy may accompany a Wilms' tumor, abdominal swelling is a more specific sign. Children with a Wilms' tumor usually have a decreased, not increased, appetite.

A 2-day postpartum client tells the nurse that she is experiencing abdominal cramps whenever she breastfeeds her baby. Which is the most appropriate response from the nurse? "Progesterone levels increase after birth of the placenta which triggers milk production and uterine contractions." "Oxytocin is released when the baby sucks which causes the uterus to contract." "The baby is feeding too frequently causing the uterus to be hyper-stimulated." "The cramps will stop after your body has expelled all blood clots from the uterus."

"Oxytocin is released when the baby sucks which causes the uterus to contract." Explanation: Afterpains, which are intermittent cramping of the uterus, tend to be noticed by multiparas rather than primiparas. In this situation, the uterus must contract more forcefully to regain its prepregnancy size. These sensations are noticed most intensely while breastfeeding because the infant's sucking causes a release of oxytocin from the posterior pituitary, increasing the strength of the contractions. After the birth of the placenta, progesterone levels decrease which triggers milk production. Frequency of breastfeeding should not cause hyper-stimulation of the uterus and the woman may continue to feel contractions as long as she is breastfeeding, regardless of the presence or absence of blood clots.

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior? "Be patient. It takes time to adjust to such a massive loss." "Talking about the past is a form of denial. We have to help you focus on today." "Reviewing your losses is a way to help you work through your grief and loss." "It's a simple escape mechanism to go back and live again in happier times."

"Reviewing your losses is a way to help you work through your grief and loss." Explanation: Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process.

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse? "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby." "RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with RH negative blood after giving birth to an Rh negative baby."

"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis

A parent of a child with sickle cell anemia confides in the nurse that the parent feels guilty about letting the child run and play with the neighborhood children and that if the parent had been a better parent, the child wouldn't have suffered a sickle cell crisis. Which response would be most appropriate? "The child is just fine now. Don't worry." "Tell me more about how you feel." "But you know that children with sickle cell anemia often have crises." "You shouldn't be so protective."

"Tell me more about how you feel." Explanation: Many parents feel guilty when their child is sick. Therefore, it's most appropriate to encourage parents to talk more about their feelings because doing so provides support and helps to develop a therapeutic relationship. Giving a stereotyped answer, such as "Don't worry," shows a lack of interest in what the parent is feeling. Commenting on the course of the disease doesn't address the parent's feelings. Being judgmental or offering an opinion can also block therapeutic communication by inhibiting the parent from discussing feelings and developing solutions.

The nurse is caring for a child who sustained a spinal cord injury in a motor vehicle collision. The child's body temperature fluctuates markedly, and the parents question why this is occurring. How should the nurse respond? "The child has developed a respiratory infection and needs antibiotics." "The child's sympathetic nervous system was damaged in the accident." "Urinary tract infections are common in children with spinal cord injuries." "It's hard to obtain accurate temperatures in children with spinal cord injuries."

"The child's sympathetic nervous system was damaged in the accident." Explanation: A common cause of temperature fluctuation in clients with spinal cord injury is damage to the sympathetic nervous system. Infections will induce a fever, but temperature will not fluctuate markedly with an upper respiratory infection. A urinary tract infection is not a cause of fluctuating temperature. The temperature of children with spinal cord injuries can accurately be obtained with numerous types of thermometers.

A client with brown hair is concerned about losing hair as a result of chemotherapy. What should the nurse tell the client? "The new growth of hair will be gray." "The hair loss is temporary." "New hair growth will always be the same texture and color as it was before chemotherapy." "Avoid use of wigs when possible."

"The hair loss is temporary." Explanation: Alopecia from chemotherapy is temporary. The new hair will not be necessarily gray, but the texture and color of new hair growth may be different. Clients who will be receiving chemotherapy should be encouraged to purchase a wig while they still have hair so that they can match the color and texture of their hair. Loss of hair, or alopecia, is a serious threat to self-esteem and should be addressed quickly before treatment.

The client is a survivor of non-Hodgkin's lymphoma. Which statement indicates the client needs additional information? "Regular screening is very important for me." "The survivor rate is directly proportional to the incidence of second malignancy." "The survivor rate is indirectly proportional to the incidence of second malignancy." "It is important for survivors to know the stage of the disease and their current treatment plan."

"The survivor rate is directly proportional to the incidence of second malignancy." Explanation: It is incorrect that the survivor rate is directly proportional to the incidence of second malignancy. The survivor rate is indirectly proportional to the incidence of second malignancy, and regular screening is very important to detect a second malignancy, especially acute myeloid leukemia or myelodysplastic syndrome. Survivors should know the stage of the disease and their current treatment plan so that they can remain active participants in their health care.

A Black client is admitted for newly diagnosed leukemia under isolation precautions where only immediate family members may visit. A White visitor arrives to visit the client. What is the nurse's best response to the visitor? "There are some visiting limitations. Are you a family member?" "You cannot visit. You will have to check in with the family." "Only immediate family members are allowed to visit today." "No visitors are allowed while the client is on isolation precautions."

"There are some visiting limitations. Are you a family member?" Explanation: The nurse should respond politely and respectfully, giving information while asking the visitor about family membership. Denying visitors in an argumentative manner, or presuming that the visitor is not a family member is disrespectful. Being on isolation precautions does not necessarily preclude visitors.

A client recruited to participate in a clinical trial to treat non-Hodgkin's lymphoma voices concerns about the adverse effects of the treatment preventing the completion of the trial. What will the nurse tell the client to protect the principle of autonomy? "Adverse effects will be managed with medication." "Participation in the trial may benefit others." "You may withdraw at any time." "There are risks and benefits associated with trial participation."

"You may withdraw at any time." Explanation: Although the nurse must tell the client how adverse effects will be treated and the risks and benefits associated with participating in the trial, the most crucial element in protecting the ethical principle of autonomy is to inform the client that they may withdraw at any time without punitive consequences. Telling the client how participation in the trial will benefit others takes the focus from the client and does not support autonomy.

A nurse is teaching a young adult female client about self-management of systemic lupus erythematosus (SLE). The client is prescribed ibuprofen, hydroxychloroquine, and cyclophosphamide. The client asks the nurse about the possibility of becoming pregnant while being treated for SLE. What is the nurse's best response? "You should speak with your healthcare provider about alternatives to taking cyclophosphamide." "You need to speak to the healthcare provider about stopping all medications prior to trying to become pregnant." "Unfortunately, having SLE greatly increases your risk for miscarriage and infertility." "Some women successfully have children, but the risk of passing on SLE is quite high."

"You should speak with your healthcare provider about alternatives to taking cyclophosphamide." Explanation: The most important piece of information in this moment is the advice to prevent pregnancy while on cyclophosphamide and to encourage the client to explore safer options if she wishes to become pregnant in the future. This drug is pregnancy category D, and there is a high risk of long-term fertility issues for women who take this medication. Tell the client that there may be a more appropriate alternative. Antimalaria medications such as hydroxychloroquine are usually continued during pregnancy, and ibuprofen poses a small risk during pregnancy. While there is a higher risk for miscarriage and fertility issues, this is not priority information for the client in this moment. While there is some genetic component to how SLE develops, there is no clear or strong pattern of heredity.

A client with lymphoma tells the nurse that a holistic practitioner has offered to treat the client with coffee enemas. How does the nurse respond? "Unproven alternative therapy can be very dangerous." "You should speak with your oncologist about this treatment." "Have you researched this practitioner's qualifications?" "This treatment is questionable. It could be dangerous."

"You should speak with your oncologist about this treatment." Explanation: In this situation, the nurse should try to maintain open communication and a strong therapeutic connection with the client. Although the treatment may be unproven, questionable, dangerous, or from an unqualified practitioner, telling the client so may make the nurse appear to be harsh and judgmental, thereby shutting down the dialogue. By referring the client to the oncologist, the nurse keeps lines of communication open and gives the client an opportunity to discuss treatment options in a difficult life situation.

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? "Retractions occur normally when children are very active." "This is very serious; you should have brought your child in sooner." "Your child is having difficulty breathing and we need to determine why." "This is an indication that your child has a respiratory infection."

"Your child is having difficulty breathing and we need to determine why." Explanation: Retractions will initially indicate a degree of respiratory compromise and increased respiratory effort. Continued assessment will determine the degree of that compromise. Retractions are not noted in general situations such as actively playing or appearing out of breath.

A client who is receiving chemotherapy expresses concern at the thought of losing hair on the head. The nurse's best response is: "Don't worry about your hair loss. A good wig can disguise that." "No one knows how long it will take your hair to grow back. You'll have to learn to cope with its loss." "A little hair loss shouldn't concern you. You have more serious things to worry about." "Your hair loss will be temporary. Would you like to tell me about your concerns?"

"Your hair loss will be temporary. Would you like to tell me about your concerns?" Explanation: Alopecia, which can occur with the administration of some chemotherapeutic agents, is psychologically disturbing for many clients even though the loss is temporary. Clients should be reassured that their hair will grow back. The nurse should encourage the client to discuss any concerns and should explore the various options available to the client (e.g., caps, wigs, scarves, turbans). Telling the client not to worry about hair loss or that there are more serious worries trivializes the client's concerns. Telling the client to learn to cope with hair loss conveys negativity and harsh judgment and is likely to demoralize the client.

A client states, "I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now." Which is the nurse's best response? "I'm sure you are frustrated and want to be well now." "Your treatment can be more effective if it is based on more specific information about your disease." "Now, you know the tests are necessary and that you are just upset right now." "I understand how you feel."

"Your treatment can be more effective if it is based on more specific information about your disease." Explanation: The nurse is an advocate for the client with leukemia who can be empowered with knowledge of the treatment. Immunologic, cytogenic, morphologic, histochemical, and other means are used to identify cell subtypes and stages of leukemia cell development for very specific and optimal treatment. The nurse should not label the client's feeling, such as frustration or emotional; only the client can identify his or her own feelings. Chastising the client is not helpful. It disavows the client's emotional state and responses to the diagnosis and involved treatment. Unless nurses have had leukemia, they cannot possibly know how the client feels even though they may be trying to offer empathy.

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? "a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" "a decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" "generally caused by decreased blood volume" "severe hypersensitivity reaction resulting in massive systemic vasodilation."

"a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" Explanation: Shock may have different causes (e.g., hypovolemia, cardiogenic, septic), but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Movement of plasma into the interstitial spaces could reflect dependent edema and sepsis. Decreased blood volume is an example of hypovolemia. A hypersensitivity reaction is an example of anaphylactic shock or distributive shock.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? Trendelenburg's 30-degree head elevation flat side-lying

30-degree head elevation Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

The nurse is reviewing assessment data of clients who may be at risk for developing malignant lymphoma. Which client would be at highest risk? A 22-year-old man with a history of mononucleosis A 25-year-old man who smokes a pack of cigarettes a day A 33-year-old man with a cousin with Hodgkin's lymphoma A 40-year-old woman with HIV

A 22-year-old man with a history of mononucleosis Explanation: Malignant lymphoma has a peak incidence between ages 20 and 30, and after age 50. It's more common in men than women and is associated with a history of Epstein-Barr virus (which causes mononucleosis). There is also an increased incidence of the disease among siblings. There is no reported association between malignant lymphoma and smoking or HIV infection.

When teaching a primigravid client about the diagnostic tests used in pregnancy, the nurse should include which information? A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Fetal heart rate increases during a nonstress test is an ominous sign and requires further evaluation with fetal echocardiography. Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks' gestation. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample.

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Explanation: The fetal biophysical profile includes fetal breathing movements, fetal body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. Normal nonstress test findings include at least two qualifying accelerations in the fetal heart rate from baseline in 20 minutes. A contraction stress test or oxytocin challenge test should be performed only on women who are at risk for fetal distress during labor. The contraction stress test is rarely performed before 28 weeks' gestation because of the possibility of initiating labor. Percutaneous umbilical cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood sample.

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort? Risk for deficient fluid volume Acute pain Activity intolerance Imbalanced nutrition: Less than body requirements

Acute pain Explanation: A nurse must collaborate with a physician to achieve the best pain control for the client. A nurse may not give medications, such as analgesics and antibiotics, without a physician order, and the nurse assesses the client's response to pain medications and provides feedback to the physician. The nurse may assist the client with nonpharmacologic activities for pain control. The nurse may implement independent nursing interventions, such as performing assessments, providing appealing fluids, pacing nursing care to promote rest and minimize client fatigue, and providing small frequent meals to address Risk for imbalanced fluid volume, Activity intolerance, and Imbalanced nutrition.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath? Soak the dressing. Remove the dressing. Administer an analgesic. Slit the dressing with blunt scissors.

Administer an analgesic. Explanation: Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply. Administer diphenhydramine. Ask the client if they are lightheaded. Give intravenous fluids. Give metoprolol. Prepare for insertion of an endotracheal tube. Check for hematuria.

Administer diphenhydramine. Ask the client if they are lightheaded. Give intravenous fluids. Prepare for insertion of an endotracheal tube. Explanation: Diphenhydramine would be administered because it reverses the effect of histamine. Lightheadedness is a symptom of anaphylactic shock. Intravenous fluids will be given to treat hypotension. Metoprolol is used to treat hypertension or chest pain. An endotracheal tube would be inserted if a respiratory arrest is imminent. Hematuria would be seen in urinary problems, such as bladder or kidney stones, enlarged prostate, kidney infection or urinary tract infection.

A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first? Administer oxygen Elevate the foot of the bed Restrict the client's fluids Prepare the client for hemodialysis

Administer oxygen Explanation: Airway and oxygenation are always the first priority. Because the client is reporting shortness of breath, and his oxygen saturation is only 89%, the nurse needs to try to increase the partial pressure of arterial oxygen by administering oxygen. The foot of the bed should not be elevated at this time as this may increase venous return to the heart and worsen pulmonary edema. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have fluids restricted.

A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, which action should the nurse take next? Administer oxygen by face mask. Begin cardiopulmonary resuscitation. Administer intravenous oxytocin. Obtain an prescription for intravenous fibrinogen.

Administer oxygen by face mask. Explanation: The client's symptoms are indicative of amniotic fluid embolism, which is a medical emergency. After calling for assistance, the first action should be to administer oxygen by face mask or cannula to ensure adequate oxygenation of mother and fetus. If the client needs cardiopulmonary resuscitation, this can be started once oxygen has been administered. If the client survives, disseminated intravascular coagulation will probably develop, and the client will need intravenous fibrinogen and heparin. Oxytocin, a vasoconstrictor, is not warranted for amniotic fluid embolism.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated? Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. Increase the IV flow rate to offset fluids lost through the therapy. Apply a topical antibiotic cream to burns to prevent infection. Administer pain medication 30 minutes before therapy to help manage pain.

Administer pain medication 30 minutes before therapy to help manage pain. Explanation: Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy.

A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action? Sit the client upright, and remove restrictive clothing from the client. Administer rapid infusion of intravenous fluids. Stabilize the spinal cord in a neutral position. Administer intravenous corticosteroid STAT.

Administer rapid infusion of intravenous fluids. Explanation: The nurse should be concerned about neurogenic shock. This complication occurs due to damage to the autonomic regulation and is most common in injuries between C1-C5 vertebra. Hypotension combined with bradycardia are the warning signs. The nurse will need to administer IV fluids, and the client may require vasopressors to maintain perfusion pressure. Sitting the client upright and removing restrictive clothing is an intervention for autonomic dysreflexia, a complication of spinal cord injury that may occur later and is manifested with hypertension, not hypotension. The client is already admitted to hospital and under treatment for the injury, so the stabilization of the spinal cord is ongoing and not an acute intervention related to the bradycardia and hypotension. Corticosteroids are not indicated or recommended for a client with these symptoms. Their use in spinal cord injury is no longer recommended.

The nurse is assessing a 2-hour-old newborn. The nurse notes nasal flaring and acrocyanosis. Which of the following is the nurse's priority intervention? Obtain blood pressure measurements on all four of the newborn's extremities. Assess the newborn's oxygen saturation. Palpate the newborn's fontanels. Auscultate the newborn's heart tones.

Assess the newborn's oxygen saturation. Explanation: Nasal flaring is a sign of respiratory distress in the newborn. Acrocyanosis is a normal finding in the newborn during transition. Assessment of the newborn's oxygen saturation is the only intervention that will assess the degree of respiratory distress. Blood pressure would be a very late sign of respiratory distress. Heart tones would not change nor would the fontanels.

The nurse is assessing a postpartum client who gave birth 6 hours earlier. The nurse notes the fundus to be deviated to the left side of the umbilicus. What action would the nurse take next? Request an order to increase the client's oxytocin infusion. Encourage the client to take a brief nap, and reassess the fundus in 1 hour. Assist the client to the bathroom to void, and reassess the fundus. Assess the perineum for swelling and bruising.

Assist the client to the bathroom to void, and reassess the fundus. Explanation: Elevation of the fundus and deviation to the side are evidence that the client's bladder is full. Having the client void and reassessing the fundus would be the appropriate intervention. Increasing the oxytocin will cause the fundus to contract but not decrease the fundal level if the bladder continues to be full. Reassessment of the fundus in 1 hour does not address the cause. Assessing the perineum checks for bleeding, but it does not address the cause.

The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. What should the nurse do next? Continue monitoring as usual; this is expected. Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. Decrease the suction and continue observing the system for changes in bubbling during the next several hours. Notify the health care provider (HCP).

Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. Explanation: There should never be constant bubbling in the water-seal system; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the leak. It is not necessary to notify the HCP until the system has been checked and the problem identified.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes? Position the client on her left side. Prepare the client for a cesarean birth. Assess the client's blood pressure. Check the fetal heart rate.

Check the fetal heart rate. Explanation: Immediately after a spontaneous rupture of the membranes, the nurse should listen to the fetal heart rate to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. Fetal heart rate should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount, and odor of the amniotic fluid should be noted.Although the optimal position for the client is side lying, this is not a priority at this time.The client is not having a precipitous birth with the fetal head at ?1 station. Therefore, preparing the client for a cesarean birth is unnecessary.Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time.

A client who underwent a lobectomy and has a water seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. What should the nurse do next? Check the tubing to ensure that the client is not lying on it or kinking it. Increase the suction. Lower the drainage bottles 2 to 3 feet (61 to 91.4 cm) below the level of the client's chest. Ensure that the chest tube has two clamps on it to prevent air leaks.

Check the tubing to ensure that the client is not lying on it or kinking it. Explanation: In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from reexpanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a health care provider's prescription. The normal position of the drainage bottles is 2 to 3 feet (61 to 91.4 cm) below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done.

The nurse is teaching the client who is receiving chemotherapy and the family how to manage possible nausea and vomiting at home. What information should the nurse include in the teaching plan? Eating frequent, small meals. Include soft foods in the diet. Drink a milkshake made with fruit every day. Limit the amount of fluid intake.

Eating frequent, small meals. Explanation: To reduce the adverse effects of chemotherapy such as nausea and vomiting, the nurse can suggest that the client eat small meals more frequently, which will be better tolerated while maintaining adequate nutrition. It is not necessary to eat soft food or milkshakes blended with fruit. Fluid intake should be encouraged to avoid dehydration.

The nurse is caring for a postterm newborn. What interventions will the nurse include in the client's plan of care? Select all that apply. Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Examine the indirect Coombs test.

Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Explanation: Postterm newborns are at risk for hypoglycemia, meconium aspiration, and hypothermia, so the nurse should assess for all these disorders. Respiratory distress can occur after meconium aspiration, so the infant should be monitored closely for increased respiratory rates, grunting, retractions, and nasal flaring. Encouraging early feedings helps prevent hypoglycemia. Double-wrapping infants in blankets after they have been removed from the radiant warmer is done to prevent hypothermia. An indirect Coombs test would be related to jaundice.

Which strategy will be most effective in improving transcultural communications with oncology clients and their families? Use touch to show concern and caring for the client. Focus attention on verbal communication skills only. Establish a rapport and listen to their concerns. Maintain eye contact at all times.

Establish a rapport and listen to their concerns. Explanation: It is important to establish rapport with the client and family by listening to verbal and nonverbal concern and showing respect for cultural differences. The use of touch or eye contact is culture-specific and cannot be generalized as an intervention for all individuals with cancer. Miscommunication between individuals of different cultures is often caused by language differences, rules of communication, age, and gender.

A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first-aid for this victim include? Select all that apply. Establish an airway with the jaw-thrust maneuver. Immobilize the spine. Logroll the victim to a side-lying position. Elevate the feet 6 inches (15.2 cm). Place a cervical collar around the neck.

Establish an airway with the jaw-thrust maneuver. Immobilize the spine. Explanation: The victim of a neck injury should be immobilized and moved as little as possible. It is also important to ensure an open airway; this can be accomplished with the jaw-thrust maneuver, which does not require tilting the head. The victim should not be rolled to a side-lying position nor have his feet elevated. Both actions can cause additional injury to the spinal cord. Placing a cervical collar causes movement of the spinal column and should not be done as a first-aid measure.

After a lobectomy for lung cancer, the nurse instructs the client to perform deep breathing exercises. What is the expected outcome of these exercises? Decrease blood flow to the lungs for rest and increased surface alveoli ventilation. Elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas exchange is increased. Control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation. Expand the alveoli and increase lung surface available for ventilation.

Expand the alveoli and increase lung surface available for ventilation. Explanation: Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. It does not decrease blood flow to the lungs or control the rate of air flow. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, thereby increasing the ventilating surface.

A mastectomy is recommended for a 68-year-old client diagnosed with breast cancer a week ago. When approached about giving consent for the mastectomy, the client says, "What's the use in trying to get rid of the cancer? It will just come back! I can't handle another thing—having diabetes is enough. Besides, I'm getting old. It would be different if I were younger and had more energy." What should the nurse do? Accept the client's decision because it is her right to choose to obtain treatment or not. Give the client information about the survival rates for clients who underwent mastectomies. Call the chaplain to speak with the client about her hopeless attitude about the future. Explore with the client her feelings about her health problems and proposed surgery.

Explore with the client her feelings about her health problems and proposed surgery. Explanation: While the client does have a right to accept or reject treatment, she has not explored her feelings, her possible mastectomy, or the future. The nurse should assist the client in exploring her feelings and moving toward a fuller understanding of her options. Giving the client survival rates indicates that the nurse feels she should have the surgery and negates her fears and concerns. While the chaplain might be helpful, this step should be done after the client has explored her feelings.

A 4-year-old who weighs 40 lb (18 kg) is brought to the emergency department with sudden onset of a temperature of 103° F (39.4° C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. What should the nurse do next? Give 600 mg of acetaminophen rectally, as prescribed. Inspect the child's throat for redness and swelling. Have equipment to secure the airway available. Obtain a specimen for a throat culture.

Have equipment to secure the airway available. Explanation: The child is exhibiting signs and symptoms of possible epiglottitis. As a result, the child is at high risk for laryngospasm and airway occlusion. Therefore, the nurse should have intubation equipment and tracheostomy tube and setup readily available should the child experience an airway occlusion. Although acetaminophen is an antipyretic, the dosage of 600 mg to be administered rectally is too high. A typical 4-year-old weighs approximately 40 lb (18 kg). The recommended dose is 125 mg. When any type of respiratory illness, and especially epiglottitis, is suspected, putting any object, including a tongue depressor for inspection or a cotton-tipped applicator to obtain a throat culture, in the back of the mouth or throat or having the child open the mouth is inappropriate because doing so may predispose the child to laryngospasm or occlusion of the airway by a swollen epiglottis.

The nurse is reviewing a client's prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth? History of postpartum hemorrhage (PPH) Urinary tract infection at 16 weeks gestational age Gravida 4, Para 3 Amniocentesis performed at 14 weeks gestational age

History of postpartum hemorrhage (PPH) Explanation: Women who have a history of PPH are at higher risk for a PPH in subsequent pregnancies. This is a significant factor for the nurse to know in planning and being prepared for the birth of the baby because this is the client's fourth labor and birth. Urinary tract infections may occur during pregnancy as the enlarging uterus puts pressure on the ureters, resulting in urinary stasis. However, there is not a significant impact on labor and birth. Following amniocentesis, the client may experience cramping and feelings of increased pressure. The associated complications with amniocentesis are proximal (infection, fetal injury, bleeding) but do not pose a long-term consequence in relation to the labor process.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Ineffective airway clearance related to edema of the respiratory passages Impaired physical mobility related to the disease process Impaired skin integrity related to disease process Risk for infection related to breaks in the skin

Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Impaired physical mobility Ineffective breathing pattern Disturbed sensory perception (tactile) Dressing or grooming self-care deficit

Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.

While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following? Intrauterine infection. Fetal meconium staining. Erythroblastosis fetalis. Normal amniotic fluid.

Intrauterine infection. Explanation: Thick, cloudy amniotic fluid indicates an intrauterine infection. Typically, the client has a fever, lethargy, and malaise. Greenish-colored amniotic fluid is associated with meconium staining. A strong yellowish color is associated with erythroblastosis fetalis because of the presence of bilirubin and hemolyzed red blood cells. The normal color of amniotic fluid is clear or with a very slight yellow tint later in pregnancy.

A woman who gave birth to her last infant by caesarean birth is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo "a trial labor." What does the nurse explain to the client that trial of labor means? Labor will be stimulated with exogenous oxytocin until delivery. The HCP needs more information to determine the presence of true labor. Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Labor will be arrested with tocolytic agents after a 2-hr period even if no fetal distress is noted.

Labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: A trial labor in this context means that the woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine whether to allow the labor to progress to delivery. If there are indications that labor is not progressing, other means of delivery are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 minutes indicates true labor. If fetal distress is noted and an emergency cesarean birth cannot be done immediately, tocolytic agents may be considered to stop contractions.

While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention? Leave the client and call the provider. Put the client in a semi-Fowler's position. Ask the client to push with the next contraction. Leave the fingers in place and press the nurse call light.

Leave the fingers in place and press the nurse call light. Explanation: When the umbilical cord precedes the fetal presenting part, it's known as a prolapsed cord. Leaving the fingers in place and calling for assistance is the safest intervention for the fetus. The nurse will need to keep the fetus off the cord to reduce cord compression. The nursing staff will contact the provider, and the client will probably require a cesarean birth to decrease the risk of fetal demise during birth. Placing the client in the semi-Fowler's position would increase the pressure of the fetus on the umbilical cord. Asking the client to push with the next contraction would force the presenting part against the cord, causing severe bradycardia and possible fetal demise.

A client has a chest tube and water seal drainage system. What should the nurse do to ensure safe and effective use of the drainage system? Verify that the air vent on the water-seal drainage system is capped when the suction is off. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. Ensure that the chest tube is clamped when moving the client out of the bed. Make sure that the drainage apparatus is always below the client's chest level.

Make sure that the drainage apparatus is always below the client's chest level. Explanation: The drainage apparatus is always kept below the client's chest level to prevent back flow of fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.

The nurse is monitoring a client receiving oxytocin. What is one possible scenario in which this drug would be indicated and used? Medically indicated induction of labor in client at 39 weeks' gestation Relief of hyperemesis gravidarum in a client at 10 weeks' gestation Treatment of dysfunctional uterine bleeding in a client who is not pregnant Cessation of premature labor in the client at 24 weeks' gestation

Medically indicated induction of labor in client at 39 weeks' gestation Explanation: Oxytocin is a medication that is used in the induction and augmentation of labor, stimulating uterine contractions. It is also used to reduce bleeding after childbirth. Oxytocin would be appropriate in the medically indicated induction for the client who is at 39 weeks' gestation, as it would help induce labor and stimulate uterine contractions. Antiemetics and intravenous fluids would be used to relieve symptoms of hyperemesis gravidarum. Treatment of dysfunctional uterine bleeding in the nonpregnant client would include hormone therapy such as oral contraceptives. Oxytocin would not halt preterm labor; it would augment labor and result in the preterm birth of the fetus.

A client is receiving dopamine hydrochloride for treatment of shock. What action should the nurse take? Administer pain medication concurrently. Monitor blood pressure continuously. Evaluate arterial blood gases at least every 2 hours. Monitor for signs of infection.

Monitor blood pressure continuously. Explanation: The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acid-base balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.

A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last two cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Perform a cardiovascular assessment every 4 hours. Ask the client to report any shortness of breath. Monitor daily platelet counts. Ask the client to report any bleeding or bruising.

Monitor daily platelet counts. Explanation: The nurse should monitor daily laboratory results as this is objective data that will alert the nurse to decreasing platelet counts. Relying on the client to report bleeding or bruising may result in the late discovery of the decreased platelet count. Performing a cardiovascular assessment every 4 hours and asking the client to report shortness of breath will not help detect early signs and symptoms of thrombocytopenia.

An adult client with lymphoma reports cough, difficulty swallowing, and shortness of breath. On physical exam the client's face and neck are swollen and the upper extremities are cyanotic. What is the nurse's best course of action? Reassure the client that that this is to be expected with this type of cancer. Monitor the respiratory pattern of the client continually. Limit physical activities. Limit activities to bed rest.

Monitor the respiratory pattern of the client continually. Explanation: The client has symptoms of superior vena cava syndrome. The symptoms are not expected side effects. The client should be monitored for respiratory distress. Activities may be limited, but the priority action of the nurse is early recognition of impending respiratory distress.

A client diagnosed with acquired immunodeficiency disorder (AIDS) 10 years ago who is now receiving treatment for non-Hodgkin lymphoma asks the nurse, "Why am I getting both chemotherapy and radiation treatments?" What information is important for the nurse to know to answer this question? Since only 10% of clients with AIDS develop non-Hodgkin lymphoma, rapid treatment may produce better, even curative results. Non-Hodgkin lymphoma occurring in clients with AIDS is usually fast growing and both treatments may bring about an initial positive result. The best treatment for AIDS-related non-Hodgkin lymphoma now is the same treatment as those clients without AIDS. When non-Hodgkin lymphoma is detected early in the client with AIDS, only a series of chemotherapy treatments is typically used.

Non-Hodgkin lymphoma occurring in clients with AIDS is usually fast growing and both treatments may bring about an initial positive result. Explanation: Non-Hodgkin lymphomas in AIDS clients is usually an aggressive disorder and treatment typically consists of both chemotherapy and radiation therapy. Rapid treatment may produce an initial positive response; however, the duration of this positive response is a short period of time. AIDS clients who develop non-Hodgkin lymphoma do not do as well as clients without AIDS due to an altered immune system. Treatment options include chemotherapy, chemotherapy with radiation, stem cell transplantation, or newer therapies in clinical trials.

A nurse is caring for a client receiving radiation for Hodgkin's lymphoma who begins to exhibit confusion. Upon further assessment, the nurse notes that the client has warm, flushed, dry skin; a heart rate of 110 beats per minute; and a temperature of 101.8° F (38.8° C). Which is the nurse's next best action? Call a code. Notify the healthcare provider. Perform a thorough neurological exam. Place the client in a high Fowler's position.

Notify the healthcare provider. Explanation: The client is exhibiting signs and symptoms of sepsis and must be treated immediately. A neurological exam is not warranted and is time consuming at this point. A code is not necessary, as there is no indication that the client is pulseless or not breathing. The high Fowler's position will not change the outcome.

The nurse on the previous night shift documented that the lungs of a client with lung cancer were CTA (clear to auscultation) in all fields. While doing the shift assessment, the day shift nurse noticed decreased breath sounds, especially in the right lower lobe. Which action is the nurse's best choice? Report the findings to the charge nurse for documentation follow up with the previous shift's nurse. Document the findings as the only action, as this is expected in clients with lung cancer. Notify the physician of the change in client status. Call radiology for an X-ray to confirm findings.

Notify the physician of the change in client status. Explanation: Pleural effusion is a common complication of lung cancer. Fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Documentation of abnormal findings without any follow-up is an error in the nursing process. Ordering an X-ray is not an independent nursing action.

The nurse is planning a presentation about ovarian cancer to a group of women. Which topic should receive priority attention in the lesson plan? Ovarian cancer signs and symptoms are often vague until late in development. Ovarian cancer should be considered in any woman older than 30 years of age. A rigid board-like abdomen is the most common sign. Methods for early detection have made a dramatic reduction in the mortality rate due to ovarian cancer.

Ovarian cancer signs and symptoms are often vague until late in development. Explanation: Ovarian cancer is rarely diagnosed early. Methods for mass screening and early detection have not been successful. Signs and symptoms are often vague until late in development. Ovarian cancer should be considered in any woman older than 40 years of age who has vague abdominal and/or pelvic discomfort or enlargement, a sense of bloating, or flatulence. Enlargement of the abdomen due to the accumulation of fluid is the most common sign.

A client asks the nurse what PSA is. The nurse should reply that it stands for prostate-specific antigen, which is used to screen for prostate cancer. protein serum antigen, which is used to determine protein levels. pneumococcal strep antigen, which is a bacteria that causes pneumonia. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.

A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of lorazepam and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. What should the nurse do in order of priority from first to last? All options must be used. Page the ED healthcare provider and prepare to give diazepam intravenously. Monitor the client's safety and place seizure pads on the cart rails. Ask the friend about the client's medical history and current medications. Record the time, duration, and nature of the seizures.

Page the ED healthcare provider and prepare to give diazepam intravenously. Monitor the client's safety and place seizure pads on the cart rails. Record the time, duration, and nature of the seizures. Ask the friend about the client's medical history and current medications. Explanation: The nurse should first obtain a prescription for and administer diazepam to stop the status epilepticus. The nurse should next prevent injury by using seizure pads. Recording the time, duration, and nature of the seizures will be important for ongoing treatment. Finally, the nurse can attempt to obtain information about medication use and abuse history from the friend until the client is able to do so for themself.

A child has just returned to the pediatric unit following placement of a ventriculoperitoneal shunt for hydrocephalus. The child is placed in a supine position. What is the nurse's priority intervention? Assess intake and output. Place the child on the side opposite the shunt. Teach on ventriculoperitoneal shut location. Administer oral pain medication as ordered.

Place the child on the side opposite the shunt. Explanation: Following shunt placement surgery, the child would be placed on the side opposite of the surgical site to prevent pressure on the shunt valve. Intake and output will also need to be assessed, but that is not the nurse's priority. The child is usually on nothing-by-mouth status until the nasogastric (NG) tube is removed and bowel sounds return. Also, pain medication should be administered by an intravenous route initially postoperatively. Teaching, if able, begins preoperatively. If not, teaching is not the first nursing intervention when returning to the pediatric unit.

A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take? Place the client on her left side and start supplemental oxygen, as ordered. Administer I.V. oxytocin, as ordered. Ease the client's anxiety by assuring her that everything will be all right. Massage the client's fundus.

Place the client on her left side and start supplemental oxygen, as ordered. Explanation: The client's signs and symptoms indicate abruptio placentae, which decreases fetal oxygenation. To maximize fetal oxygenation, the nurse should place the client on her left side to increase placental blood flow to the fetus and administer supplemental oxygen, as ordered, to increase the blood oxygen level. Administering oxytocin is not appropriate because this drug stimulates contractions, which further reduce fetal oxygenation. The nurse cannot assure the client that everything will be all right, only that everything possible will be done to help her and her fetus. Fundal massage is used only during the postpartum period to control hemorrhage.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? Place the mother in a knee-to-chest position. Palpate the cord for pulsations before notifying the physician. Attempt an external cephalic rotation. Restore circulation by stimulating the cord with a sterile glove.

Place the mother in a knee-to-chest position. Explanation: The knee-to-chest position helps lift the presenting part off the umbilical cord. If, upon vaginal examination, a loop of cord is discovered, the nurse should keep gloved fingers in the vagina and push on the fetal presenting part to keep the part off the cord, thus relieving cord compression until the physician or midwife arrives. It is inappropriate to attempt an external cephalic rotation. Cord pulsations may not be felt; therefore, oxygen should be administered and electronic fetal monitoring should be put in place immediately to monitor the fetal heart rate and well being.

The nurse is caring for a primigravida client who has been admitted to the labor and birth unit. Assessment reveals fetal malpresentation, green amniotic fluid, and a fetal heart rate (FHR) of 98 beats/minute. What is the nurse's priority intervention? Administer IV oxytocin as prescribed. Apply an internal fetal scalp electrode. Instruct the client to push. Prepare for an emergency cesarean birth.

Prepare for an emergency cesarean birth. Explanation: Because the abnormal FHR and amniotic fluid color suggest fetal distress, the nurse should prepare for an emergency cesarean birth. Giving oxytocin may increase fetal distress. Applying a fetal scalp electrode and having the client push would not address this emergency situation.

The nurse caring for the laboring client performs a sterile vaginal exam. Exam results are dilated 10 cm, effaced 100%, and +2 station. What is the priority nursing intervention? Initiate oxytocin infusion. Call anesthesia to give epidural anesthesia. Prepare for birth of the neonate. Assess for rupture of the membranes.

Prepare for birth of the neonate. Explanation: A client who is fully dilated is about to begin pushing. Appropriate actions for this time include assessing vital signs every 15 minutes, positioning for effective pushing, and preparing for delivery. Oxytocin is administered to induce labor or to help the uterus contract after birth; it would be inappropriate to administer to a client entering the second stage of labor. It is inappropriate to insert an epidural when the client is ready to start pushing. Status of membranes would have been determined during the sterile vaginal exam.

A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client? Start an IV and give penicillin G every 4 hours until birth. Administer tocolytics as prescribed until the active lesions are healed. Administer valacyclovir 500 mg orally every 6 hours while in active labor. Prepare the client and partner for a cesarean birth as soon as possible.

Prepare the client and partner for a cesarean birth as soon as possible. Explanation: For a client with active genital herpes lesions, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Penicillin G is given for a bacterial colonization of group B streptococcus. Tocolytics are given to stop labor; they are not appropriate treatment. Valacyclovir is a treatment for an active herpes infection, but would not work in time for the client to deliver vaginally.

The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin's lymphoma. What is the primary goal of care for this client? Maintain fluid balance. Obtain sufficient exercise. Prevent infection. Avoid depression.

Prevent infection. Explanation: The client with Hodgkin's lymphoma who has had radiation therapy is prone to infection; therefore, the primary goal is to prevent infection. The nurse instructs the client to perform frequent hand hygiene, avoid crowded areas, and report a temperature over 100°F (37.7°C). Maintaining fluid balance, exercising, and maintaining mental health are also important, but these are not primary goals at this time.

The nurse working on a neurological unit is assigned a client with spinal cord injury. Which nursing actions can the nurse delegate to the nursing student on the unit? Select all that apply. Provide pin care. Assess the client's neurologic status for changes in movement and strength. Monitor traction ropes and weights while moving the client. Administer oral medication to decrease muscle spasticity. Assess for autonomic dysreflexia.

Provide pin care. Administer oral medication to decrease muscle spasticity. Explanation: The nursing student can provide pin care and administer oral medications. The nursing student should be mentored when monitoring traction during client repositioning, performing neurologic assessments, and assessing for autonomic dysreflexia, which means they cannot yet be delegated these tasks to complete on their own.

Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? Monitor the neonate's color and cry every 4 hours. Feed the neonate with a bottle every 3 hours. Obtain extracorporeal membrane oxygenation equipment. Provide warm, humidified oxygen in a warm environment.

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.

The nurse assessment of a 6-month-old infant brought to the outpatient clinic reveals a respiratory rate of 52 breaths/min, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which action would be most appropriate? Administer a nebulizer treatment. Send the infant for a chest radiograph. Refer the infant to the emergency department. Provide teaching about cold care to the mother.

Refer the infant to the emergency department. Explanation: Based on the assessment findings of increased respiratory rate, retractions, and wheezing, this infant needs further evaluation, which could be obtained in an emergency department. Without a definitive diagnosis, administering a nebulizer treatment would be outside the nurse's scope of practice unless there was a prescription for such a treatment. Sending the infant for a radiograph may not be in the nurse's scope of practice. The findings need to be reported to a HCP who can then determine whether or not a chest radiograph is warranted. The infant is exhibiting signs and symptoms of respiratory distress and is too ill to send out with just instructions on cold care for the mother.

The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next? Document these results on the medical record. Report the elevated potassium level immediately. Report the elevated calcium level immediately. Refrain from reporting the results because the client is in hospice care.

Report the elevated calcium level immediately. Explanation: The normal calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.63 mmol/L). Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide, or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.

The nurse notes that the dialysate drainage of a client receiving peritoneal dialysis is cloudy. Which action should the nurse take? Flush the catheter with saline solution. Report the finding to the healthcare provider. Encourage the client to increase the intake of oral fluids. Instill an additional liter of dialysate solution.

Report the finding to the healthcare provider. Explanation: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid that should be immediately reported to the healthcare provider. Flushing the catheter could enhance the development of an abdominal infection. The client receiving peritoneal dialysis is in renal failure and most likely is on a fluid restriction. Additional fluids will not affect the presence of cloudy dialysate. It is beyond the nurse's scope of practice to instill an additional liter of dialysate. This action could alter the client's fluid and electrolyte balance.

The nurse is developing a discharge plan with a client who is receiving chemotherapy to treat lymphoma. What should the nurse include in the plan? Select all that apply. Wear a mask if leaving the house. Rest as needed. Avoid people with colds or flu. Decrease the protein in your diet. Contact the health care provider (HCP) if a fever develops.

Rest as needed. Avoid people with colds or flu. Contact the health care provider (HCP) if a fever develops. Explanation: The nurse should teach the client to obtain as much rest as need, to avoid people who have a cold or the flu, and to report a fever to the HCP. It is not necessary for the client to wear a mask when going out of the house, but the client should avoid large crowds where there may be people with contagious diseases. It is not necessary to decrease the protein in the diet, but rather, the client should eat a well-balanced diet. The client may need to change some foods if the client has side effects of the chemotherapy and may need to obtain more calories.

What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure? Prepare for temporary peritoneal dialysis or hemodialysis. Restrict sodium and potassium and restrict fluids as ordered. Provide a diet high in protein and restrict fluids as ordered. Monitor for hypotension and maintain accurate intake and output records.

Restrict sodium and potassium and restrict fluids as ordered. Explanation: In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure.

A nurse is caring for a client diagnosed with acute kidney injury with an indwelling urinary catheter. The nurse notes that the total urine output for the previous 24 hours is 35 ml. What action should the nurse perform first? Insert an intravenous catheter, and encourage the client to increase oral intake. Teach the client about what to expect during hemodialysis treatments. Scan the client's bladder to determine if residual volumes are present. Notify the healthcare provider that the client meets the criteria for anuria.

Scan the client's bladder to determine if residual volumes are present. Explanation: The client with acute kidney injury can potentially progress to anuria (urine output less than 50 ml/24 hr), which can be an indication for beginning hemodialysis. The healthcare provider will also consider the client's kidney function test results when making this decision. However, the nurse should first check the accuracy of the measured output by performing a bladder scan for residual volume that can confirm if the catheter is occluded or if anuria is indeed present. Only once anuria is confirmed should the nurse notify the healthcare provider and then take actions based on the prescribed interventions.

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication? Relief from episiotomy pain. Contraction of the uterus. Softening of the stool. Aid in sleeping.

Softening of the stool. Explanation: Docusate sodium is a stool softener, used to assist in bowel elimination. The client is at risk for constipation because of decreased food and fluid intake and pain from the episiotomy. Numerous analgesics, such as ibuprofen or acetaminophen, could be used to treat episiotomy pain, helping the client achieve comfort and thus fall asleep. Oxytocin is used to contract the uterus.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. The alveoli expand and increase the lung surface available for ventilation.

The alveoli expand and increase the lung surface available for ventilation. Explanation: Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? The cord lengthens outside the vagina. There is decreased vaginal bleeding. The uterus cannot be palpated. The uterus changes to discoid shape.

The cord lengthens outside the vagina. Explanation: The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of (rather than a decrease in) vaginal blood. Usually, when placenta detachment occurs, the uterus becomes firmer and changes in shape from discoid to globular. This process takes about 5 minutes. If the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage.

A client with ovarian cancer asks the nurse, "What is the cause of this cancer?" Which is the most accurate response by the nurse? Use of oral contraceptives increases the risk of ovarian cancer. Women who have had at least two live births are protected from ovarian cancer. There is less chance of developing ovarian cancer when one lives in an industrialized country. The risk of developing ovarian cancer is related to environmental, endocrine, and genetic factors.

The risk of developing ovarian cancer is related to environmental, endocrine, and genetic factors. Explanation: A definitive cause of carcinoma of the ovary is unknown, and the disease is multifactorial. The risk of developing ovarian cancer is related to environmental, endocrine, and genetic factors. The highest incidence is in industrialized Western countries. Endocrine risk factors for ovarian cancer include women who are nulliparous. Use of oral contraceptives does not increase the risk for developing ovarian cancer, but may actually be protective.

An overweight adolescent has been diagnosed with type 2 diabetes. What should the nurse do to increase the client's self-efficacy to manage the disease? Provide the client with a written daily food and exercise plan. Discuss eliminating junk food in the home with the parents. Arrange for the school nurse to weigh the child weekly. Utilize a peer with type 2 diabetes to role model lifestyle changes.

Utilize a peer with type 2 diabetes to role model lifestyle changes. Explanation: Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client.

Parents bring a 10-month-old boy with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply. Weigh the child. Listen to bowel sounds. Palpate the posterior fontanel. Obtain vital signs. Assess pitch and quality of the child's cry.

Weigh the child. Listen to bowel sounds. Obtain vital signs. Assess pitch and quality of the child's cry. Explanation: Common shunt complications are obstruction, infection, and disconnection of the tubing. The signs presented by the child indicate increased intracranial pressure from a shunt malfunction, which could be caused by an infection, such as peritonitis or meningitis. By listening to bowel sounds, the nurse will note if peritonitis might be a possibility. Intracranial pressure manifests as a bulging or taut anterior fontanel, but the posterior fontanel is typically closed. Obtaining vital signs would assess for signs of infection, such as elevated temperature or, possibly, Cushing's triad (elevated blood pressure, slow pulse, and depressed respirations). A high-pitched cry is a sign of increased intracranial pressure. Weighing the child, while it would not help identify the cause of the problem, would help determine the severity of the dehydration from vomiting.

A nurse receives the assignment of clients for the shift. Following the report, which client should the nurse see first? a client with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit a client with a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant a client 3 days after a kidney transplant with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L after dialysis a client experiencing mild pain from urolithiasis

a client 3 days after a kidney transplant with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L after dialysis Explanation: A sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L in a client immediately following dialysis should be the priority assessment. Pinkish mucus discharge in the appliance bag is a normal finding for a client who's had an ileal conduit, as are a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L in a client who's had a kidney transplant. Although the nurse should further assess mild pain from urolithiasis, this is an expected finding and not a priority in relation to the client with abnormal sodium and potassium levels.

The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client? a brightly lit private room at the end of the hall from the nurses' station a semiprivate room midway down the hall from the nurses' station a private room with many windows that is near the operating room a darkened private room as close to the nurses' station as possible

a darkened private room as close to the nurses' station as possible Explanation: A primigravid client diagnosed with preeclampsia has the potential for developing seizures (eclampsia). This client should be in a room with the least amount of stimulation possible to reduce the risk of seizures and as close to the nurses' station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risk of seizures, as can being in a semiprivate room with roommate, visitors, conversation, and noise.

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: a decrease in the blood flow through the kidneys." an obstruction of urine flow from the kidneys." a blood clot that formed in the kidneys." structural damage to the kidney."

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.

A client who is 29 weeks pregnant comes to the labor and childbirth unit. She states that she is having contractions every 8 minutes. The client is also 3 cm dilated. Which can the nurse expect to administer? Select all that apply. folic acid a β-2 agonist betamethasone Rohm(D) immune globulin (RhoGAM) intravenous fluids nalbuphine

a β-2 agonist betamethasone intravenous fluids Explanation: The nurse can expect that a β-2 agonist that relaxes smooth muscle will be administered to halt contractions; that betamethasone, a corticosteroid, will be administered to decrease the risk of respiratory distress to the neonate if preterm birth occurs; and that intravenous fluids will be given to expand the intravascular volume and decrease contractions if dehydration is the cause. Folic acid is a mineral recommended throughout pregnancy (especially in the first trimester) to decrease the risk of neural tube defects. RhoGAM is given to Rh-negative clients who have been, or may have been, exposed to Rh-positive fetal blood. Nalbuphine is an opioid analgesic used during labor and birth.

A client at 7 weeks' gestation is being treated for a ruptured ectopic pregnancy in the emergency department. The client's vital signs are blood pressure 84/45 mmHg, heart rate 122 beats/min, respiratory rate 26 breaths/min, temperature 98.6°F (36.8°C). What is the nurse's priority? administering fluid resuscitation and preparing the client for surgery administering analgesics and teaching the client about methotrexate monitoring vaginal discharge and performing focused abdominal assessment ensuring strict infection control and providing psychosocial support

administering fluid resuscitation and preparing the client for surgery Explanation: Most of the actions listed with the exception of teaching about methotrexate are interventions that may be performed by the nurse caring for a client with a ruptured ectopic pregnancy. The fact that the rupture has already occurred means methotrexate is contraindicated. The nurse should monitor vaginal losses, assess the client's abdomen, treat her pain, and prevent infection while providing psychosocial support. However, the priority is maintaining perfusion pressure and ensuring swift surgical intervention to correct this life-threatening medical emergency. When an ectopic pregnancy ruptures, the client experiences intra-abdominal bleeding. The fact that the client's blood pressure, heart rate, and respiratory rate all reflect hemodynamic instability means the nurse's priority is maintenance of perfusion through fluid resuscitation and correcting the blood loss through the surgical intervention.

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis advocating for the client by ordering Meals on Wheels 5 days a week asking the physician to write an order for home skilled nursing assessments and interventions asking an occupational therapist to evaluate the client at home

asking the physician to write an order for home skilled nursing assessments and interventions Explanation: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home healthcare. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home healthcare. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

A nurse is teaching an older adult who has had a left modified radical mastectomy with axillary node dissection about lymphedema. What should the nurse tell the client about when lymphedema occurs? if all cancer cells are not removed in older women at any time after surgery only with radical mastectomy

at any time after surgery Explanation: Lymphedema after breast cancer surgery is the accumulation of lymph tissue in the tissues of the upper extremity extending down from the upper arm. It may occur at any time after surgery in women of any age. It is caused by the interruption or removal of lymph channels and nodes after axillary node dissection. Removal results in less efficient filtration of lymph fluid and a pooling of lymph fluid in the tissues on the affected side. Treatments or interventions should be instituted as soon as lymphedema is noted to prevent or reduce further progression. Range-of-motion exercises, elevation, and avoidance of injury in the affected arm are important when completing client teaching. The health care provider (HCP) may also prescribe a compression sleeve. Lymphoma is not caused by failure to remove all cancer cells. Lymphedema can occur after any surgery that disrupts lymph flow, not just radical mastectomy.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? avoiding using deodorant soap on the irradiated areas applying talcum powder to the irradiated areas daily after bathing wearing a lead apron during direct contact with the client removing thoracic skin markings after each radiation treatment

avoiding using deodorant soap on the irradiated areas Explanation: Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

The nurse assists with a precipitous birth in an outpatient setting. While waiting for more advanced care, the nurse places the infant skin to skin with the mother and encourages breastfeeding. What are the desired outcomes of skin-to-skin care with early breastfeeding? Select all that apply. beginning the parental-infant bonding process preventing neonatal hypothermia providing glucose to the neonate contracting the mother's uterus preventing maternal infection

beginning the parental-infant bonding process preventing neonatal hypothermia providing glucose to the neonate contracting the mother's uterus Explanation: The nurse places the newborn skin to skin with the mother immediately following birth for many reasons. The practice facilitates transition to the extra uterine environment. Skin-to-skin contact helps to begin the parental-infant bonding process, and helps prevent neonatal hypothermia. Early breastfeeding provides the neonate with nutrients to prevent hypoglycemia. Breastfeeding stimulates the natural production of oxytocin, which helps reduce the potential for uterine atony. Skin-to-skin care with early breastfeeding does not reduce the risk of maternal infections.

The nurse is caring for a client prescribed a tocolytic agent. The nurse takes immediate action based on what assessment finding? blood glucose of 170 mg/dL (9.4 mmol/L) maternal heart rate of 114 beats/min bilateral crackles on lung auscultation peripheral pulse strength of +2

bilateral crackles on lung auscultation Explanation: Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Bilateral crackles on lung auscultation is a sign of pulmonary edema, and prompt action would be required. A serum glucose level of 170 mg/dL (9.4 mmol/L) is elevated and should be reported, but it is not life-threatening. Tocolytics may cause tachycardia and increased cardiac output with bounding arterial pulsations. A peripheral pulse strength of +2 indicates a slightly lower than normal level that is not an immediate cause for concern.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's blood pressure. hemoglobin level. temperature. heart rate.

blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note that which symptom should be reported immediately? hemorrhoids blurred vision dyspnea on exertion increased vaginal mucus

blurred vision Explanation: During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they do not require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 130/70 mm Hg. The nurse should report which changes, if they occur, to the health care provider (HCP)? Select all that apply. decreasing urinary output decreasing systolic blood pressure bradycardia widening pulse pressure tachycardia increasing diastolic blood pressure

bradycardia widening pulse pressure Explanation: The nurse should immediately report changes that indicate increasing intracranial pressure (ICP): bradycardia, increasing systolic pressure, and widening pulse pressure. As ICP increases and the brain becomes more compressed, respirations become rapid, BP decreases, and the pulse slows further; these are very ominous signs. Decreased arterial BP and tachycardia can indicate bleeding elsewhere in the body. Decreasing urinary output indicates decreased tissue perfusion. The nurse monitors changes and notifies the HCP if trends continue.

A client has given birth to a preterm neonate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that breast milk contains antibodies that help protect her neonate. commercial formula will provide better nutrition for the neonate. breast-feeding can be started when the neonate is ready for discharge. the neonate will be less likely to develop an infection on commercial formula.

breast milk contains antibodies that help protect her neonate. Explanation: Studies have proven that breast milk provides preterm neonates with better protection from infections such as necrotizing enterocolitis because of the antibodies contained in the milk. Commercial formula doesn't provide any better nutrition than breast milk. Breast milk feedings can be started as soon as the neonate is stable. The neonate is more likely to develop infections when fed formula rather than breast milk.

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur? infertility cervical cancer pelvic inflammatory disease rectal cancer

cervical cancer Explanation: HPV infection, or genital warts, can lead to dysplastic changes of the cervix, referred to as cervical intraepithelial neoplasia. The development of cervical cancer remains the largest threat of all condyloma-associated neoplasias. Infertility, pelvic inflammatory disease, and rectal cancer are not complications of genital warts.

What is a risk factor for women who have human papillomavirus (HPV)? sterility cervical cancer uterine fibroid tumors irregular menses

cervical cancer Explanation: Women who have HPV are much more likely to develop cervical cancer than women who have never had the disease. Cervical cancer is now considered a sexually transmitted disease. Regular examinations, including Papanicolaou tests, are recommended to detect and treat cervical cancer at an early stage. Girls and women as well as boys and men (around ages 9 to 26 depending on the vaccine) should receive a vac

The nurse provides care to a client with severe burns. During the recuperation phase, the client becomes withdrawn. For what potential contributor to the client's change in demeanor should the nurse assess? dependence and unwillingness to be discharged changes in body image and self-esteem decrease in coping abilities pressure from family and friends to be more social

changes in body image and self-esteem Explanation: During the recuperation phase, the client is likely to consider the body image implications of this injury. Sensitivity to body image and self-esteem issues are anticipated concerns. The client has suffered through the most difficult part. There are fewer concerns regarding dependence and coping abilities in the recuperation phase. The pressure from family and friends to be more social would be a reaction to the client's withdrawing from social interactions rather than a causative factor of the withdrawal.

A client is being treated for facial burns caused by a house fire. Which assessment should the nurse make a priority? presence of a gag reflex checking for airway patency ability to speak capillary refill time

checking for airway patency Explanation: Because the client has received facial burns, the client may have inhaled smoke and toxic fumes from the house fire. The priority is assessing for a patent airway. Smoke inhalation does not affect the gag reflex. The voice might sound raspy because of inhaling soot, but there should not be any change in the ability to speak. Capillary refill time assesses perfusion, which is not a priority for this client.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims, all adults, should be transported to a burn center? Select all that apply. The victim who has: chemical spills on both arms third-degree burns of both legs first-degree burns of both hands respiratory distress inhaled smoke

chemical spills on both arms third-degree burns of both legs respiratory distress inhaled smoke Explanation: Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility.

A nurse is taking a history from the parents of a 11-year-old child admitted with Reye's syndrome. Which illness should the nurse expect the parents to report their child having the previous week? chickenpox bacterial meningitis strep throat Lyme disease

chickenpox Explanation: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome.

The nurse examines the laboratory results for a client and notes a white blood cell (WBC) count of 112,000/mm3 (112 x109/L). What condition does the nurse review the client's medical record for to best explain this abnormal result? chronic myelogenous leukemia acute bacterial infection acute viral infection Hodgkin's disease

chronic myelogenous leukemia Explanation: WBC count (leukocyte count) normally has an upper normal range of about 11,000/mm3 (11x109/L). While bacterial infections can increase the WBC moderately (up to 50,000/mm3 [50x109/L]), white counts above 100,000/mm3 (100x109/L) indicate a pathology such as leukemia is present. Some clients with chronic myelogenous leukemia can have WBC counts as high as 500,000/mm3 (500x109/L). This is due to the high number of granulocytes that are counted on the WBC test, even though these cells are not functioning as normal WBCs. Hodgkin's disease (Hodgkin's lymphoma) is a disease of the lymph nodes and can affect bone marrow, often resulting in decreased rather than increased WBCs. Acute viral infections can result in slightly lower than normal WBC counts due to viral effects on bone marrow activity.

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? deep breathing turning coughing passive range-of-motion (ROM) exercises

coughing Explanation: Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? pupillary asymmetry irregular breathing pattern involuntary posturing declining level of consciousness (LOC)

declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment being received for SIADH is effective? Select all that apply. decrease in body weight rise in blood pressure; drop in heart rate absence of wheezes in the lungs increase in urine output decrease in urine osmolarity

decrease in body weight increase in urine output decrease in urine osmolarity Explanation: SIADH is an abnormality involving an excessive release of antidiuretic hormone. The predominant feature is water retention with oliguria, edema, and weight gain. Successful treatment should result in a reduction of weight, increased urine output, and a decrease in urine concentration osmolarity.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? decreased deep tendon reflexes cool skin temperature rapid pulse rate tingling in the toes

decreased deep tendon reflexes Explanation: Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax? Cheyne-Stokes respirations increased fremitus diminished or absent breath sounds on the affected side decreased sensation on the affected side

diminished or absent breath sounds on the affected side Explanation: Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds. Cheyne-Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and increases with inspiration.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may dislodge the autografts. increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers.

dislodge the autografts. Explanation: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

A nurse is completing a prenatal assessment on a woman who is 28 weeks pregnant with gestational hypertension. Which findings should be reported to the primary care provider? Select all that apply. dull headache weight gain of 1 lb (500 g) per week blurred vision 1+ urine protein fundal height of 28 centimeters

dull headache blurred vision 1+ urine protein Explanation: The nurse must be alert for any signs and symptoms of superimposed preeclampsia in women with gestational hypertension. Dull headache, blurred vision, and protein in urine are all classic signs of preeclampsia in pregnancy and must be reported to the primary care provider immediately. Weight gain of 1 lb (500 grams) per week is an expected finding. Fundal height of 28 cm is an expected finding.

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.

After a mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. The nurse should teach the client to: apply an elastic bandage to the affected extremity. limit range-of-motion exercises in the shoulder and elbow. elevate the affected arm on a pillow. use diuretics as necessary to decrease swelling.

elevate the affected arm on a pillow. Explanation: The client should be taught to elevate the affected arm on a pillow to promote venous return and lymphatic drainage of the area.Applying an elastic bandage is inappropriate because constriction of the extremity should be avoided.Range-of-motion exercising is not limited. Rather, it is encouraged. Diuretics are not used to control lymphedema.

A 36-year-old multigravid client is admitted to the hospital with possible ruptured ectopic pregnancy. When obtaining the client's history, which finding would be most important to identify as a predisposing factor? urinary tract infection marijuana use during pregnancy episodes of pelvic inflammatory disease use of estrogen-progestin contraceptives

episodes of pelvic inflammatory disease Explanation: Anything that causes a narrowing or constriction in the fallopian tubes so that a fertilized ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy. Pelvic inflammatory disease is the most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic pregnancy is not related to urinary tract infections. Use of marijuana during pregnancy is not associated with ectopic pregnancy, but its use can result in cognitive reduction if the mother's use during pregnancy is extensive. Progestin-only contraceptives and intrauterine devices have been associated with ectopic pregnancy.

A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl (70mmol/L). The most therapeutic pharmacologic intervention would be to administer ferrous sulfate. epoetin alfa. filgrastim. enoxaparin.

epoetin alfa. Explanation: Chronic renal failure diminishes the production of erythropoietin by the kidneys and leads to a subnormal Hb level. (Normal Hb level is 13 to 18 g/dl in men and 12 to 16 g/dl in women.) An effective pharmacologic treatment for this is epoetin alfa, a recombinant erythropoietin. Because the client's anemia is caused by a deficiency of erythropoietin and not a deficiency of iron, administering ferrous sulfate would be ineffective. Neither filgrastim, a drug used to stimulate neutrophils, nor enoxaparin (low-molecular-weight heparin) will raise the client's Hb level.

The nurse is assessing an hour-old newborn. Which observations would the nurse note as being abnormal? Select all that apply. respiratory rate of 56 heart rate of 135 expiratory grunting temperature of 97.4° F (36.3° C) nasal flaring

expiratory grunting temperature of 97.4° F (36.3° C) nasal flaring Explanation: Respiratory rate for a newborn is 30-60 and the heart rate is 120-160. Expiratory grunting and nasal flaring are signs of respiratory distress in the newborn. Temperature for a newborn should be between 97.5° F (36.4° C) and 99° F (37.2° C).

After the nurse reviews the primary health care provider's (HCP's) explanation of amniocentesis with a multigravid client, which complication, if stated by the client, indicates that she needs more teaching about the procedure? risk of infection possible miscarriage risk of club foot fetal organ malformations

fetal organ malformations Explanation: There is little risk for fetal organ malformations from amniocentesis. One of the primary risks of amniocentesis is stimulation of the uterus and possible miscarriage. Other risks include hemorrhage from penetration of the placenta, infection of the amniotic fluid, and puncture of the fetus. Club foot has been associated with amniocentesis, especially when it is performed before 15 weeks.

A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for: hemoptysis. focal ischemia. petechiae. hematuria.

focal ischemia. Explanation: Clinical manifestations of microvascular thrombosis are those that represent a blockage of blood flow and oxygenation to the tissue that results in eventual death of the organ. Examples of microvascular thrombosis include acute respiratory distress syndrome, focal ischemia, superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma. Hemoptysis, petechiae, and hematuria are signs of hemorrhage.

The family of an older adult with terminal cancer asks about having hospice services. What should the nurse tell the family? Hospice care: focuses only on the needs of the client. can only be provided in the inpatient setting. is staffed exclusively by professional health care workers. focuses on supportive care for the client and family.

focuses on supportive care for the client and family. Explanation: Hospice care focuses on supportive care for the client and family. Care for the family may continue throughout the bereavement period. Hospice care involves care of the client at home as well as in an inpatient setting. Although professional care is provided in hospice, family members, volunteers, and unlicensed nursing personnel (UAP) also participate in the care of the client.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment? free, easy movement of the joints absence of paralytic foot drop external rotation of the hips at rest absence of tissue ischemia over bony prominences

free, easy movement of the joints Explanation: ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Foot drop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.

A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic? mammogram Papanicolaou (Pap) testing every 6 months contacting the American Cancer Society (Canadian Cancer Society) genetic counseling

genetic counseling Explanation: The nurse should suggest that the client ask the physician about genetic counseling. Genetic counseling is indicated for those at high risk because of family or personal cancer history. Genetic counseling involves obtaining a detailed medical and three-generational family history; calculating a personalized risk assessment; providing options for prevention, surveillance, and genetic testing; coordinating and interpreting genetic testing; and developing a management plan based on the test results. Mammography will assist with early detection of most breast cancers, but it won't establish a risk assessment and provide options for prevention, surveillance, and genetic testing. Pap testing every 6 months assists in early detection of most cervical cancers, but it won't establish a risk assessment. Contacting the American Cancer Society (Canadian Cancer Society) won't help assess the client's risk for developing cancer.

A client who's 3 months pregnant with her first child reports increasing morning sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal heart tones. The nurse should suspect which complication of pregnancy? fetal demise ectopic pregnancy hyperemesis gravidarum gestational trophoblastic disease

gestational trophoblastic disease Explanation: Gestational trophoblastic disease causes increased nausea and vomiting, uterine enlargement beyond that expected for the number of weeks' gestation, absence of fetal heart tones, and vaginal spotting. Because the client exhibits most of these signs, she requires further evaluation. In fetal demise, uterine size decreases; the client's fundal height of 20 cm at 3 months' gestation is too large to indicate fetal demise. Absence of fetal heart tones is a sign of ectopic pregnancy; however, a fundal height of 20 cm doesn't support that diagnosis. Although hyperemesis gravidarum causes increased nausea and vomiting, the client's enlarged uterus suggests a different problem.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for: disposal of emesis or other bodily secretions. handling of the dislodged radiation source. disposal of the client's eating utensils. storage of the radiation dose.

handling of the dislodged radiation source. Explanation: Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the client. Disposal of eating utensils cannot lead to radiation exposure. Radioactive dose materials are kept only in the radiation department.

A nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (Canadian Cancer Society) guidelines, the nurse should recommend that the women perform breast self-examination annually. have a mammogram annually. have a hormonal receptor assay annually. have a physician conduct a clinical examination every 2 years.

have a mammogram annually. Explanation: The American Cancer Society (Canadian Cancer Society) guidelines state that women age 40 and older should have a mammogram annually and a clinical examination at least annually (not every 2 years). All women should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

During the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints? headache, blurred vision, and facial and extremity swelling abdominal pain, urinary frequency, and pedal edema diaphoresis, nystagmus, and dizziness lethargy, chest pain, and shortness of breath

headache, blurred vision, and facial and extremity swelling Explanation: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most clients with preeclampsia have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia.

Which finding is a risk factor for hypovolemic shock? hemorrhage antigen-antibody reaction gram-negative bacteria vasodilation

hemorrhage Explanation: Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.

What conditions would the nurse expect to find in in a preterm neonate suffering from cold stress? yellowish undercast to the skin color increased abdominal girth hyperactivity and twitching slowed respirations

hyperactivity and twitching Explanation: A neonate with cold stress must produce heat through increased metabolism, causing oxygen use to increase and glycogen stores to be quickly depleted leading to hypoglycemia. Hyperactivity and twitching are signs of hypoglycemia.Yellowish undercast to the skin color suggests jaundice related to excessive bilirubin levels, not cold stress.Increased abdominal girth suggests abdominal distention, possibly indicating necrotizing enterocolitis. It is unrelated to cold stress or possible hypoglycemia.Increased, not slowed, respirations are associated with neonatal cold stress and hypoglycemia.

A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition? morning sickness eclampsia hyperemesis gravidarum hydramnios

hyperemesis gravidarum Explanation: Hyperemesis gravidarum differs from the nausea and vomiting (morning sickness) that normally occur during pregnancy. It's characterized by excessive vomiting that can lead to dehydration and starvation. Without treatment, metabolic changes can lead to severe complications, even death, of the fetus or mother. Eclampsia is the most serious form of gestational hypertension. It's characterized by hypertension, seizures, coma, edema, and proteinuria. Hydramnios is an overproduction of amniotic fluid that causes uterine distension.

The nurse should be especially alert for what problem when caring for a term neonate, who weighed 10 lb (4,500 g) at birth, 1 hour after a vaginal birth? hypoglycemia hypercalcemia hypermagnesemia hyperbilirubinemia

hypoglycemia Explanation: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Therefore, the nurse needs to assess for the possibility of complications. Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other common complications for an LGA neonate include hyperbilirubinemia from the bruising and polycythemia, cephalohematoma, caput succedaneum, molding, phrenic nerve paralysis, and a fractured clavicle. However, hyperbilirubinemia would not be evident 1 hour after birth. Hypercalcemia is not usually found in the LGA neonate. Hypocalcemia is common in infants of diabetic mothers. Hypermagnesemia may occur in neonates whose mothers received large doses of magnesium sulfate to treat severe preeclampsia.

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? cardiogenic hypovolemic neurogenic anaphylactic

hypovolemic Explanation: A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. What would be the priority problem for this neonate? impaired skin integrity hyperglycemia risk for impaired patent-infant-child attachment impaired gas exchange

impaired gas exchange Explanation: The priority problem for the neonate with probable MAS is impaired gas exchange related to the effects of respiratory distress. Obstruction of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing adequate respirations is the primary goal. Impaired skin integrity is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Hypoglycemia tends to be a problem for large-for-gestational-age babies, not hyperglycemia. If the parents do not express interest or concern for the neonate, then risk for impaired parent-infant-child attachment may be appropriate once the airway is established.

The nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize? impaired skin integrity impaired physical mobility disturbed body image constipation

impaired skin integrity Explanation: Impaired skin integrity is a serious problem for the burned child. The open skin causes fluid to leak and can contribute to fluid and electrolyte issues. Also, because the skin is open there is a portal for infectious organisms. The diagnoses of impaired physical mobility, disturbed body image, and constipation are relevant in the care of the child with burns, but they are concerns for later in the recovery process.

On admission, the client's arterial blood gas (ABG) values were: pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, repeat blood gas values are: pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/L). This change would indicate: impending respiratory failure. improving respiratory status. developing respiratory alkalosis. obstruction in the chest tubes.

improving respiratory status. Explanation: The ABG values after chest tube insertion are returning to normal, indicating that treatment is effective.Impending respiratory failure would be indicated by a decreasing PaO2 or an increasing PaCO2.The client is not alkalotic because the pH values are below 7.35.If the chest tubes were obstructed, the client's respiratory status would deteriorate.

When teaching a group of pregnant adolescent clients about reproduction and conception, the nurse is correct when stating that fertilization occurs: in the uterus. when the ovum is released. near the fimbriated end. in the first third of the fallopian tube.

in the first third of the fallopian tube. Explanation: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.

A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider? inappropriate parental concern for the degree of injury absence of parents to question about the injury inappropriate response of the child to the injury incompatibility between the child's history and the injury

incompatibility between the child's history and the injury Explanation: Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. For example, the child may have a skull fracture but the parents state that the child fell off of the sofa. The other criteria also may suggest child abuse but are less reliable indicators.

A client with a large cerebral intracranial hemorrhage was given mannitol to decrease intracranial pressure (ICP). What therapeutic effect should the nurse anticipate from mannitol? increased urine output pupils that are bilaterally 7mm and nonreactive evidence of rebound cerebral hypertension normal blood urea nitrogen (BUN) and creatinine levels

increased urine output Explanation: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubules, thus increasing urine output. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage, seen in herniation associated with a deteriorating cerebellar hemorrhage. No information is given about abnormal BUN and creatinine levels, or that mannitol is being given for renal dysfunction. Rebound cerebral hypertension is an adverse and undesired complication from ongoing mannitol use.

The nurse is witnessing the client's signature on the informed surgical consent for an abdominal hysterectomy. The nurse should be certain the client understands that what will be the outcome of this surgery? decreased libido. infertility. depression. weight gain.

infertility. Explanation: The client needs to understand that with removal of the uterus she will no longer be able to bear children or have menstrual periods. The surgical procedure should not change her libido or sexual functioning. Research does not support the idea that hysterectomy contributes to depression or weight gain. Research demonstrates that women who have managed health problems for some time before the hysterectomy may actually have a more positive effect, with less worry about their health condition, contraception, or pregnancy.

An 11-year-old is admitted for treatment of an asthma attack. Which finding indicates immediate intervention is needed? thin, copious mucous secretions productive cough intercostal retractions respiratory rate of 20 breaths/minute

intercostal retractions Explanation: Intercostal retractions indicate an increase in respiratory effort, which is a sign of respiratory distress. During an asthma attack, secretions are thick, the cough is tight, and respiration is difficult (and shortness of breath may occur). If mucous secretions are copious but thin, the client can expectorate them, which indicates an improvement in the condition. If the cough is productive it means the bronchospasms and the inflammation have been resolved to the extent that the mucus can be expectorated. A respiratory rate of 20 breaths/minute would be considered normal and no intervention would be needed.

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed? laxative anticholinergic antacid demulcent

laxative Explanation: After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat

The health care provider (HCP) orders an amniocentesis for a primigravid client at 37 weeks' gestation to determine fetal lung maturity. Which is an indicator of fetal lung maturity? amount of bilirubin present presence of red blood cells Barr body determination lecithin-sphingomyelin (L/S ratio)

lecithin-sphingomyelin (L/S ratio) Explanation: To determine fetal lung maturity, the sample of amniotic fluid will be tested for the L/S ratio. When fetal lungs are mature, the ratio should be 2:1. Bilirubin indicates hemolysis and, if present in the fluid, suggests Rh disease. Red blood cells should not appear in the amniotic fluid because their presence suggests fetal bleeding. Barr body determination is a chromosome analysis of the sex chromosomes that is sometimes used when a child is born with ambiguous genitalia.

A nurse is assessing a client with lymphoma who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms? flushing, decreased oxygen saturation, mild hypotension low-grade fever, chills, tachycardia elevated temperature, oliguria, hypotension high-grade fever, normal blood pressure, increased respirations

low-grade fever, chills, tachycardia Explanation: Nine days after chemotherapy, it is expected for the client to be immunocompromised. The clinical signs and symptoms of shock reflect changes in cardiac function, vascular resistance, cellular metabolism, and capillary permeability. Low-grade fever, tachycardia, and chills may be early signs of shock. The client with signs and symptoms of impending septic shock may not have decreased oxygen saturation levels. Oliguria and hypotension are late signs of shock. Urine output can be initially normal or increased.

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent: carpal tunnel syndrome. peripheral neuropathy. contractures. lymphedema.

lymphedema. Explanation: Lymphedema is a common postoperative effect of modified radical mastectomy and lymph node dissection. Elevation of the left arm and hand will allow gravity to assist lymph drainage. Other preventive measures include exercises in which the arms are elevated. Peripheral neuropathy is not associated with postoperative complications, nor are contractures. Although muscle atrophy is a potential adverse effect if the client does not exercise the left arm, it would not be prevented by elevation.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will: regain any weight lost within 4 weeks of the surgical procedure. eat three full meals a day without experiencing gastric complications. learn to self-administer enteral feedings every 4 hours. maintain adequate nutrition through oral or parenteral feedings.

maintain adequate nutrition through oral or parenteral feedings. Explanation: An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently.It is not realistic to expect the client to regain weight loss within 4 weeks of surgery.After surgery, it is recommended that the client eat six small meals a day rather than three full meals to decrease symptoms of dumping syndrome.Enteral feedings are not part of the expected outcome for gastric surgery.

The nurse is teaching the family of a client diagnosed with leukemia about ways to prevent infection. Which instruction has the most impact? bathing the client daily covering the client's mouth when coughing maintaining an intact skin integrity ingesting a plant-based diet

maintaining an intact skin integrity Explanation: A client with leukemia has a compromised immune system. Maintaining skin integrity is a priority as the skin is a barrier to pathogens. If a pathogen enters the client's system, the client may not be able to fight off the bacteria and it will multiply and spread. Bathing daily can decrease bacteria on the skin but unless there is a break in the skin, the bacteria will remain on the skin. Covering the mouth when coughing protects others but does not have an impact on the client. Ingesting a plant-based diet may be nutritious, which helps the immune system; but, this does not have the most impact.

The nurse instructs the unlicensed assistive personnel (UAP) on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to: milk the chest tubes every 4 hours. raise the collection apparatus to the height of the bed to measure the fluid level. attach the chest tubes to the bed linen to avoid tension on the tubing. mark the time and amount of drainage on the collection container.

mark the time and amount of drainage on the collection container. Explanation: It is appropriate for a UAP to mark the time of measurement and fluid level on the collection container. Milking of chest tubes is not routinely recommended but, if performed, would be the responsibility of the nurse.The collection container should not be raised to bed height because this can cause fluid to flow back toward the client. Chest tubes should not be secured to the bed linens because they could be pulled on and potentially disconnected when the client moves and turns in bed.

When assessing a client for early sepsis, which assessment finding would most concern the nurse? pale, yellow urine mean arterial pressure less than 70 mmHg two-second capillary refill purulent drainage from surgical site

mean arterial pressure less than 70 mmHg Explanation: Symptoms of early sepsis include fever with restlessness and confusion. As sepsis advances, the nurse will find a decrease in blood pressure including a mean arterial pressure (MAP) less than 70 mmHg accompanied by tachypnea and tachycardia; decreased urine output; and hyperglycemia with the absence of diabetes. Later sepsis includes the presence of shock: hypotension despite adequate fluid resuscitation along with the presence of abnormal tissue perfusion. Purulent drainage from the surgical site should be reported and a culture obtained, but would not be the greatest concern. Pale yellow urine is not a negative finding in sepsis.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? measuring and documenting the drainage in the collection chamber maintaining continuous bubbling in the water-seal chamber keeping the collection chamber at chest level stripping the chest tube every hour

measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

A nurse is caring for a client with a history of spinal cord injury. Which nursing actions can reduce the risk for autonomic dysreflexia? Select all that apply. instruct the client to wear a medical alert bracelet at all times observe the client for a pattern of temperament changes monitor the patency of the indwelling urinary catheter promote a high fiber diet, and the use of a stool softener perform a digital rectal exam to remove fecal impaction if evacuation doesn't occur within 24 hours

monitor the patency of the indwelling urinary catheter promote a high fiber diet, and the use of a stool softener Explanation: Bowel and bladder distention are common causes of autonomic dysreflexia (AD). A digital rectal exam is contraindicated for fecal impaction, as it could cause an episode of AD. No bowel movement within 24 hours does not necessarily indicate fecal impaction.

The client has second- and third-degree burns. The family asks if there is anything that can be given to the client for pain. Which analgesic would the nurse anticipate to manage the client's pain? heparin administered by IV meperidine administered by IM codeine administered by PO morphine administered by IV

morphine administered by IV Explanation: The best and most effective medication for second- and third-degree burns would be IV morphine. IM medications may not be absorbed, and codeine may not provide sufficient analgesia.

A client is born with severe tetralogy of Fallot and transferred to a pediatric hospital. The nurse caring for the client anticipates administering which medications during, or to prevent, a "tet spell?" Select all that apply. indomethacin morphine sulfate propranolol hydrochloride prednisone digoxin

morphine sulfate propranolol hydrochloride Explanation: The nurse would expect to administer propranolol as a preventive measure, and morphine sulfate during a tet spell to decrease infundibular spasm. Indomethacin is used to relieve pain, swelling, and joint stiffness; prednisone is used for suppressing the immune system and inflammation; and digoxin is a drug used to treat congestive heart failure.

A client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous? eversion of the right nipple and mobile mass nonmobile mass with irregular edges mobile mass that is soft and easily delineated nonpalpable right axillary lymph nodes

nonmobile mass with irregular edges Explanation: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.

The nurse assesses a 2-month old infant with hydrocephalus with a ventriculoperitoneal shunt. The nurse obtains the infant's vital signs. In order to obtain the most significant information about the child's status, which assessment should the nurse make next? status of posterior fontanelle pupillary reaction to light occipital frontal head circumference presence of the primitive reflex

occipital frontal head circumference Explanation: Measuring the occipital frontal head circumference over time is the most obvious way to monitor if hydrocephalus is worsening or improving in an infant. The infant exhibits sunsetting of the eyes, which is a sign of hydrocephalus. Pupillary reactions may be decreased or unequal, but these measurements do not give as much information about changes in the infant's status. The posterior fontanelle usually closes by 2 months in a typically developing infant. Finding the posterior fontanelle still open in an infant with hydrocephalus would not be unexpected and would not necessarily be an indicator of the severity of the disorder. A finding of primitive reflexes in a 3-month-old infant would be an expected finding.

A nurse working in the emergency department receives arterial blood gas results on four clients. Which laboratory result requires immediate nursing intervention? pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg pH 7.48, PaCO2 35 mm Hg, and PaO2 65 mm Hg pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg pH 7.33, PaCO2 58 mm Hg, and PaO2 64 mm Hg

pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg Explanation: The pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg indicate that the client has severe uncompensated respiratory acidosis and hypoxemia. A PaO2 under 60 indicates respiratory failure. This client needs oxygen immediately to prevent further deterioration. The remaining ABG's pH 7.48, PaCO2 35 mm Hg, and PaO2 65 mm Hg is indicative of uncompensated metabolic alkalosis, pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg slight respiratory acidosis and pH 7.33, PaCO2 58 mm Hg, and PaO2 64 mm Hg uncompensated respiratory acidosis with hypoxemia are all not as severely hypoxemic as the client with a PaO2 of 58.

The nurse is caring for an 8-year-old child with a head injury. Which of the following symptoms are important for the nurse to control to prevent an increase in intracranial pressure? Select all that apply. pain coughing agitation sedation nausea

pain coughing agitation Explanation: Persistent and frequent coughing, pain, and agitation are all potential causes for increased intracranial pressure in the pediatric population. Sedation is used to reduce agitation and metabolic needs of the brain and therefore would not increase ICP in the pediatric population. Nausea may be a symptom of increased intracranial pressure, but does not cause it.

When the nurse assesses a toddler with Wilms' tumor, what should the nurse avoid? measuring the child's chest circumference palpating the child's abdomen placing the child in an upright position measuring the child's occipitofrontal circumference

palpating the child's abdomen Explanation: The abdomen of the child with Wilms' tumor should not be palpated because of the danger of disseminating tumor cells. Techniques such as measuring the occipitofrontal circumference (which is done in children younger than 18 months of age because the anterior fontanel closes between 12 and 18 months of age), upright positioning, and measuring chest circumference are not necessarily contraindicated; however, the child with Wilms' tumor should always be handled gently and carefully.

During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which problem? abdominal cramping hyperactive bowel sounds paralytic ileus profuse diarrhea

paralytic ileus Explanation: A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and rectum. Paralytic ileus often occurs as a result of decreased gastrointestinal muscle innervation. The nurse evaluates this by auscultating the abdomen. Because the client has a thoracic spinal cord injury, the client may not feel abdominal cramping. Additionally, auscultation would provide no evidence of cramping. Hyperactive bowel sounds would be evidenced with increased peristalsis; peristalsis would probably be diminished with this injury. Profuse diarrhea, resulting from increased peristalsis, would not be an expected finding. Diarrhea would be more commonly associated with a gastrointestinal infection.

The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding? passage of meconium by the fetus maternal intrauterine infection Rh incompatibility between mother and fetus maternal sexually transmitted disease

passage of meconium by the fetus Explanation: Greenish-colored amniotic fluid is caused by the passage of meconium, usually secondary to a fetal insult during labor. Meconium passage also may be related to an intact gastrointestinal system of the neonate, especially those neonates who are full term or of postdate gestational age. Amnioinfusion may be used to treat the condition and dilute the fluid. Cloudy amniotic fluid is associated with an infection caused by bacteria or a sexually transmitted disease. Severe yellow-colored fluid is associated with Rh incompatibility or erythroblastosis fetalis.

When assessing a neonate who was born at 30 weeks gestation, a nurse notes bounding femoral pulses, a palpable thrill over the suprasternal notch, tachycardia, tachypnea, and crackles. The nurse suspects ventricular septal defect. patent ductus arteriosus. tetralogy of Fallot. atrial septal defect.

patent ductus arteriosus. Explanation: Patent ductus arteriosus causes tachycardia, tachypnea, a palpable thrill over the suprasternal notch, hepatomegaly, bounding peripheral pulses, widened pulse pressure, a continuous or systolic heart murmur, increased heart pulsation, and signs of respiratory distress or heart failure (such as increasing respiratory effort, crackles or moist breath sounds, feeding intolerance, fatigue, and decreasing urine output). Ventricular and atrial septal defects rarely cause signs at birth, although a neonate with an atrial septal defect may have a systolic murmur. With tetralogy of Fallot, the neonate typically has cyanosis, dyspnea, and a continuous murmur that is audible across the back.

A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who is caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the dressing when? Select all that apply. per hospital policy every 72 hours when the dressing is becoming loose when the dressing is soiled when the site is reddened

per hospital policy when the dressing is becoming loose when the dressing is soiled when the site is reddened Explanation: Research demonstrates that central lines are a large infection risk for clients. The dressing must be clean, dry, and intact to be effective. Sterile dressing change is indicated when the dressing does not meet this criteria; otherwise it is changed per hospital policy.

A nurse attending to the discharge of two clients learns that they will be caring for a client newly diagnosed with leukemia. The nurse has limited time to evaluate the new client. What should be the nurse's priority consideration as the nurse plans the time? evaluating the new client's teaching needs and coping mechanisms performing basic care tasks before evaluating the new client verifying the availability of adequate support staff reading the client's chart to see if the nurse has gathered all the necessary information

performing basic care tasks before evaluating the new client Explanation: Although it's important to evaluate a new client's teaching needs and coping mechanisms, the nurse's first priority is to attend to the client's need for physical care. Verifying the availability of adequate support staff is important, but not the most pressing need in relation to the new client. A client with newly diagnosed leukemia has many levels of need. After the nurse has addressed the client's basic physiologic needs, the nurse should thoroughly evaluate the client's coping skills and psychosocial support system. The nurse may incorporate their evaluation into basic care and explore it in more detail at a later time.

Which signs and symptoms of leukemia would lead the nurse to suspect the client has thrombocytopenia? Select all that apply. fever petechiae epistaxis anorexia bone pain shortness of breath

petechiae epistaxis Explanation: Children with acute lymphocytic leukemia have a reduced platelet count (thrombocytopenia), reduced red blood cell count (anemia), and reduced white blood cell count (neutropenia) because of unrestricted proliferation of immature white blood cell. Chemotherapy is used to treat leukemia and contributes to thrombocytopenia, neutropenia, and anemia. Clients with thrombocytopenia are at risk for bleeding. Petechiae (small red or purple spots on the skin) and epistaxis (nose bleeds) are both signs of bleeding. A fever is a result of a decreased white blood cell count. Anorexia and dyspnea (shortness of breath) are a result of a decreased red blood cell count. Bone pain is a result of stress on the bone related to the unrestricted proliferation of the leukemic blast cells.

A client is receiving monthly doses of chemotherapy for treatment of stage III colon cancer. Which laboratory results should the nurse report to the oncologist before the next dose of chemotherapy is administered? Select all that apply. hemoglobin of 14.5 g/dL (145 g/L) platelet count of 40,000/mm3 (40 X 109/L) blood urea nitrogen (BUN) level of 12 mg/dL (4.3 mmol/L) white blood cell count of 2,300/mm3 (2.3 X 109/L) temperature of 101.2° F (38.4° C) urine specific gravity of 1.020

platelet count of 40,000/mm3 (40 X 109/L) white blood cell count of 2,300/mm3 (2.3 X 109/L) temperature of 101.2° F (38.4° C) Explanation: Chemotherapy causes bone marrow suppression and risk of infection. A platelet count of 40,000/mm3 (40 X 109/L) and a white blood cell count of 2,300/mm3 (2.3 X 109/L) are low. A temperature of 101.2° F (38.4° C) is high and could indicate an infection. Further assessment and examination should be performed to rule out infection. The BUN, hemoglobin, and specific gravity values are normal.

The nurse is caring for a woman who gave birth vaginally to a healthy 6 pound (2.72 kg) newborn after a 2-hour labor at 37 weeks gestation. For which complication will the nurse assess as a priority due to the increased risk in this client? postpartum infection delay in lactation postpartum hemorrhage delayed infant bonding

postpartum hemorrhage Explanation: The client's labor was under 3 hours in length, which meets the definition for precipitous labor. This increases the risk for postpartum hemorrhage but decreases the risk for infection. The client is at early term (37 weeks) and gave birth vaginally without any noted complications, so there should be no delay in either lactation or infant bonding.

The nurse covers the myelomeningocele of a neonate with a sterile dressing. Which statements direct the nurse's action? conserving energy preventing infection promoting neural tube sac drainage conserving body heat

preventing infection Explanation: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Conserving energy is not a concern for neonates, including those with a myelomeningocele. Like all neonates, a neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.

The nurse determines that the parent understands the diet restrictions for a child with chronic renal failure who is receiving peritoneal dialysis when the parent reports providing a diet involving which components? sodium and water restrictions high protein and carbohydrates high potassium and iron protein and phosphorus restrictions

protein and phosphorus restrictions Explanation: Regulation of the diet is the most effective means, besides dialysis, for reducing renal excretion. Dietary phosphorus is restricted, which reduces the protein load on the kidneys. Clients are also given substances to bind phosphorus in the intestines to prevent absorption. Limited protein in the diet should include foods high in essential amino acids. Foods high in fat and carbohydrate are used to increase caloric intake. Sodium and water may not be restricted because of the continual loss of sodium and water through the dialysate. Iron-rich foods are commonly high in protein.

A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include: blood pressure 140/90 mm Hg; pulse 80 beats/min; respiratory rate 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic? headaches blood glucose level proteinuria peripheral edema

proteinuria Explanation: The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The peripheral edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. While, the preeclamptic client may significant edema in the face and hands, edema can be caused by other factors and is not part of the diagnostic criteria. Headaches are significant in pregnancy-induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis.

A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to place ice packs on the client's painful joints. administer antibiotics. provide oral and I.V. fluids. administer folic acid supplements.

provide oral and I.V. fluids. Explanation: Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but aren't a priority during sickle cell crisis.

Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer? repositioning the client immediately after administering pain medication reassessing the client after administering pain medication reassuring the client after administering pain medication readjusting the pain medication dosage as needed

reassessing the client after administering pain medication Explanation: It is essential for the nurse to evaluate the effects of pain medication after it has had time to act. Although other interventions may be appropriate, continual reassessment is most important to determine the effectiveness and need for additional intervention, if any. Repositioning could provide some comfort, but assessment of the client's pain level is essential. Reassuring the client is important, but it will be of no value unless the nurse evaluates the client's pain level. To readjust the pain dosage is appropriate only if titration is prescribed by the health care provider (HCP).

The nurse is teaching a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. When the nurse is evaluating the effectiveness of the tube placed lowest in the pleural cavity, what is the purpose of this chest tube? preventing clots removing air removing fluid facilitating "milking" of the tubes

removing fluid Explanation: Fluid accumulates in the base of the pleura postoperatively. The lower chest tube, called the posterior or lower tube, will drain serous and serosanguineous fluid that accumulates as a result of the surgical procedure. A larger-diameter tube is usually used for the lower tube to ensure drainage of clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The practice of "milking" the tubes to prevent clots is becoming less common; the surgeon's prescriptions must be followed regarding this procedure.

The nurse is assessing a client for a possible brainstem herniation. Which findings assist in confirming this diagnosis? Select all that apply. respiratory rate decreased from 14 to 10 breaths per minute and irregular blood pressure increased from 118/70 to 140/82 mmHg urine output decreased from 45 to 30 mL/hour body temperature decreased from 97.8°F (36.5°C) to 96.9°F (36.1°C) heart rate increased from 80 to 120 beats per minute

respiratory rate decreased from 14 to 10 breaths per minute and irregular blood pressure increased from 118/70 to 140/82 mmHg Explanation: Cushing's triad is the presence of hypertension, bradycardia, and irregular respiration in a client with increased intracranial pressure. This protects brain tissue when the brain has poor perfusion. It is a late sign of increased intracranial pressure and indicates brainstem herniation is imminent unless immediate interventions are initiated. Increased heart rate, increased temperature, and decreased urine output do not directly indicate brainstem herniation.

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.

Which nursing diagnosis is the priority for a client with burns to 35% of the body surface area? fluid volume overload altered cardiac output risk for infection altered tissue perfusion

risk for infection Explanation: The greatest risk to a client with burns to more than 25% of the body is infection and sepsis, which can be fatal. Therefore, the priority is to acknowledge that the client is at risk for infection and to implement interventions that address this. The other diagnoses, although applicable to a burn client, are not the priority.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? impaired urinary elimination toileting self-care deficit risk for infection activity intolerance

risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, toileting self-care deficit, and activity intolerance may be pertinent but are secondary to the risk of infection.

A client with a modified radical mastectomy is being discharged. The client has been very reluctant to discuss the surgery or her situation. The nurse making assignments should delegate the client's care to the: unlicensed assistive personnel (UAP) because the client is stable and being discharged. same nurse who has cared for her the past 3 days, for continuity of care. nurse in orientation who needs experience in discharge instructions. nurse with the most bed baths, because this client will not need a bath.

same nurse who has cared for her the past 3 days, for continuity of care. Explanation: Continuity of care is crucial for this client to feel more comfortable about asking questions and discussing her care at home.A UAP does not have the educational preparation (registered nursing license) to provide discharge instructions.It is not appropriate to assign this client to a nurse in orientation or one who needs assistance; the priority need is continuity of care.

The nurse is performing a routine assessment of a 37-week pregnant client. What should the nurse implement during this prenatal visit? screening for group B strep and STIs administration of rubeola vaccine education about hospital registration administration of RhoGAM if the mother is Rh-negative

screening for group B strep and STIs Explanation: During each prenatal visit the mother's blood pressure, weight, and urine are assessed and the fundal height is measured. Between 37 and 40 weeks, screening for group B streptococcus, gonorrhea, and chlamydia is also done. The mother should have already preregistered at the hospital. RhoGAM is given at 28 weeks. The measles vaccine is given postpartum to the mother who is not immunized.

A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. The client's family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms? platelet count 300,000/mm3 (0.3 L) serum calcium level 13.8 mg/dl (0.766 mmol/L) serum sodium level of 133 mEq/L (133 mmol/L) hemoglobin of 9.8 g/dl (98 g/L)

serum calcium level 13.8 mg/dl (0.766 mmol/L) Explanation: Excessive thirst, constipation, dehydration, confusion, and altered mental state are possible signs of hypercalcemia. Hypercalcemia is common in multiple myeloma because of the increased bone destruction. A platelet count of 300,000/mm3 is normal and wouldn't cause the client's symptoms. A sodium level of 133 mEq/L is slightly decreased but wouldn't cause confusion and excessive thirst. A hemoglobin of 9.8 g/dl level is slightly low but isn't likely responsible for the client's symptoms.

An 18-year-old pregnant client tells the nurse that she is concerned that she may not be able to take care of herself during her pregnancy. She states that she is not sure what prenatal care is available, or if she should access it. The nurse should recognize that the client: may not take care of herself. may not be fit to take care of a child. needs to find a second job. should be referred to community resources available for pregnant women.

should be referred to community resources available for pregnant women. Explanation: The client needs to know that many freely available resources exist, and the nurse should help her to find such resources. It doesn't necessarily mean that the client has no interest in caring for herself or her child.

The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess? shoulder dystocia immature lung function hypoglycemia small birth weight

shoulder dystocia Explanation: This neonate exhibits findings of a post-term infant. Typically they are larger in size and more at risk for having shoulder dystocia. Immature lung function, hypoglycemia, and small birth weight are more common in pre-term infants.

A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client expresses concerns about insurance coverage and financial needs. Based on this information, to whom would the nurse initiate a referral? hospice financial advisor social services case management

social services Explanation: A social worker can be extremely beneficial in helping clients identify additional personal and community funding resources and support groups. A hospice referral is not appropriate for a client with a new diagnosis who is seeking treatment. The nurse would not refer the client to a financial advisor as these advisors typically focus on wealth management, not the identification of resources. A referral to case management would be contingent on the client's insurance requirements and would not address the immediate concern.

On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment? radiation therapy surgical procedure chemotherapy none (At this advanced stage, ovarian cancer isn't treatable.)

surgical procedure Explanation: Ovarian cancer usually requires aggressive treatment — initially, surgery. The client will require a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. Radiation therapy is palliative for a client in this advanced stage of the disease. Chemotherapy also is largely palliative during this stage; however, prolonged remissions have been achieved in some clients.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. systolic blood pressure urine output breath sounds cerebral perfusion pressure level of pain

systolic blood pressure cerebral perfusion pressure Explanation: The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expect the newborn to exhibit? Select all that apply. tachypnea with excessive secretions effective latch to the breast easily consoled and comforted sensitive gag reflex hyperactivity and increased muscle tone

tachypnea with excessive secretions sensitive gag reflex hyperactivity and increased muscle tone Explanation: Newborns exposed to drugs while in utero can have tachypnea, excessive secretions, a sensitive gag reflex, hyperactivity, and increased muscle tone. Newborns exposed to drugs while in utero will not be satisfied with breastfeeding or eating and are not easily consoled or comforted.

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. What are desired outcomes of this therapy? Select all that apply. temperature, 98° F (36.7° C); pulse, 72 beats/min; respiratory rate, 14 breaths/min urinary output less than 30 mL/h fetal heart rate with late decelerations blood pressure less than 140/90 mm Hg deep tendon reflexes 2+ magnesium level = 5.6 mg/dL (2.8 mmol/L)

temperature, 98° F (36.7° C); pulse, 72 beats/min; respiratory rate, 14 breaths/min deep tendon reflexes 2+ magnesium level = 5.6 mg/dL (2.8 mmol/L) Explanation: The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromuscular transmissions and decreasing the amount of acetylcholine liberated. The primary goal of magnesium sulfate therapy is to prevent seizures. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (rpm). Rates at 12 rpm or lower are associated with respiratory depression and are seen with magnesium toxicity. Renal compromise is identified with a urinary output of less than 30 mL/hour. A fetal heart rate that is maintained within the 112 to 160 range is desired without later or variable decelerations. While extreme elevations of blood pressure must be treated, achieving a normal pressure carries the risk of decreasing perfusion to the fetus. Deep tendon reflexes should not be diminished or exaggerated. The therapeutic magnesium sulfate level of 5 to 8 mg/dL (2.5 to 4 mmol/L) is to be maintained.

Which client is at highest risk for colorectal cancer? the client who smoked 1 pack a day for 30 years the client who follows a vegetarian diet the client who has been treated for Crohn's disease for 20 years the client with a family history of lung cancer

the client who has been treated for Crohn's disease for 20 years Explanation: Clients over age 50 who have a history of inflammatory bowel disease are at risk for colon cancer. The client who smokes is at high risk for lung cancer. While the exact cause is not always known, other risk factors for colon cancer are a diet high in animal fats, including a large amount of red meat and fatty foods with low fiber, and the presence of colon cancer in a first-generation relative.

The nurse is performing triage in the emergency department. Which client should be seen first? the client with flank pain radiating to the groin the client who has an open fracture of his radius the client with burns to the chest and neck with singed nasal hair a primipara who is 39 weeks pregnant having contractions every 15 minutes

the client with burns to the chest and neck with singed nasal hair Explanation: The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair indicates an inhalation injury, which may lead to the development of respiratory distress syndrome. Flank pain that radiates to the groin is an indication of renal calculi, but this would not take precedence over a client with an obstructed airway. The fracture is not life-threatening and would not take precedence over the client with airway problems. The primipara still has time before the baby comes.

A nurse obtains the antepartum history of a client who is 6 weeks pregnant. Which finding is a concern? the client's participation in low-impact aerobics three times per week the client's consumption of six to eight cans of beer on weekends the client's consumption of four to six small meals daily the client's practice of taking a multivitamin supplement daily

the client's consumption of six to eight cans of beer on weekends Explanation: Consuming any amount or type of alcohol isn't recommended during pregnancy because it increases the risk of fetal alcohol syndrome or fetal alcohol effect. The nurse should teach the client about these risks. If the client is accustomed to moderate exercise, she may continue to engage in low-impact aerobics during pregnancy. Eating frequent, small meals helps maintain the client's energy level by keeping the blood glucose level relatively constant. Taking a multivitamin supplement daily and eating a balanced diet are recommended during pregnancy.

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? the head of the bed elevated 15 to 20 degrees Trendelenburg's position left Sims position the head elevated on two pillows

the head of the bed elevated 15 to 20 degrees Explanation: The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 15 to 20 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: electrical burns of the hands and arms causing arrhythmias. thermal burns to the head, face, and airway resulting in hypoxia. chemical burns on the chest and abdomen. secondhand smoke inhalation.

thermal burns to the head, face, and airway resulting in hypoxia. Explanation: Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

The primary health care provider (HCP) prescribes betamethasone for a 34-year-old multigravid client at 32 weeks' gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks' gestation. The nurse explains that this drug is given for which reason? to enhance fetal lung maturity to counter the effects of tocolytic therapy to treat chorioamnionitis to decrease neonatal production of surfactant

to enhance fetal lung maturity Explanation: Betamethasone therapy is indicated when the fetal lungs are immature. The fetus must be between 28 and 34 weeks' gestation and birth must be delayed for 24 to 48 hours for the drug to achieve a therapeutic effect. Antibiotics would be used to treat chorioamnionitis. Betamethasone is not an antagonist for tocolytic therapy. It increases, not decreases, the production of neonatal surfactant.

A client with chronic cancer pain has been receiving opiates for 4 months. She rated the pain as an 8 on a 10-point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to 8 again. What is the most likely explanation for the increasing pain? development of an addiction to the opioids tolerance to the opioid withdrawal from the opioid placebo effect has decreased

tolerance to the opioid Explanation: Tolerance to an opioid occurs when a larger dose of the analgesic is needed to provide the same level of pain control. The risk of addiction is low with opioids to treat cancer pain. There are no data to support that this client is experiencing withdrawal. Although the client may have experienced a placebo effect at one time, placebo effects tend to diminish over time, especially in regard to chronic cancer pain.

A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer? gait belt lift sheet transfer chair transfer board

transfer board Explanation: A transfer board is made of smooth, rigid, low-friction material and is placed under the client to provide a slick surface. The surface of the board reduces friction and limits the force needed to move the client from the bed to a stretcher. A gait belt would be contraindicated because the client is unable to use the leg muscles because of paralysis. A lift sheet would be used in bed to reposition the client. It would not be helpful when transferring the client from the bed to the chair. A transfer chair converts to a stretcher. This type of device is not required for the client.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? insufficient perineal stretching rapid, progressive labor umbilical cord prolapse fetal prematurity

umbilical cord prolapse Explanation: Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth.

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 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.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? diaphragmatic breathing use of accessory muscles pursed-lip breathing controlled breathing

use of accessory muscles Explanation: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which complication? postpartum "blues" uterine atony intrauterine infection urinary tract infection

uterine atony Explanation: Because birth occurs so rapidly and the fetus is propelled quickly through the birth canal, the major complication of a precipitous birth is a boggy fundus, or uterine atony. The neonate should be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the health care provider (HCP) will probably prescribe administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm. There is no relationship between a precipitous birth and postpartum "blues" or intrauterine infection. Postpartum "blues" usually do not occur until about 3 days postpartum, and symptoms of postpartum infection usually occur after the first 24 hours. There is no relationship between a precipitous birth and urinary tract infection even though the birth has been accomplished under clean rather than sterile technique. Symptoms of urinary tract infection typically begin on the first or second postpartum day.

During the fourth stage of labor, the client should be assessed carefully for uterine atony. complete cervical dilation. placental expulsion. umbilical cord prolapse.

uterine atony. Explanation: Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. After delivery of the placenta is the fourth stage and assessing for relaxed uterus helps determine uterine atony. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus's presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The client should be assessed for a visible or palpable umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration during contractions. The presence of umbilical cord prolapse requires an emergency delivery.

The nurse is assigned a client with end-stage ovarian cancer with recurrent ascites, and the client is to undergo paracentesis. Which activity is best to delegate to an experienced licensed practical nurse (LPN/VN)? completing the client admission vital signs every 15 minutes after the paracentesis providing discharge instructions after the paracentesis obtaining a paracentesis tray from central supply

vital signs every 15 minutes after the paracentesis Explanation: To delegate nursing care effectively, a nurse must know the client's condition, the competence and scope of practice of all nursing team members, and the level of supervision needed for the delegated nursing care task. The nurse must also consider the training, cultural competence, and experience of the delegate. Delegating nursing care requires critical thinking and professional judgment to ensure that the delegated nursing care task is the right task for the right person, the task is delegated under the right circumstances, the delegate receives the right directions and communication, and the performance of the task is properly supervised and evaluated. An experienced LPN/LVN would monitor and report vital signs to the RN. The paracentesis tray can be obtained by the unit clerk or unlicensed assistive personnel (UAP). The admission assessment and teaching require the RN's expertise and education.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when the nurse notes tidal movements or fluctuations in which compartment of the system as the client breathes? water-seal chamber air-leak chamber collection chamber suction control chamber

water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

A client is receiving chemotherapy for treatment of acute lymphocytic leukemia. During discharge preparation, which topic is most important for the nurse to discuss with the client and caregivers? how to help the client adjust to an altered body image how to increase the client's interactions with peers the need to decrease the client's activity level ways to prevent infection

ways to prevent infection Explanation: Because overwhelming infection is the most common cause of death in clients with leukemia, preventing infection is the most important teaching topic. Although promoting adjustment to an altered body image and increasing peer interactions are important, they don't address life-threatening concerns and therefore take lower priority. The nurse should advise the caregivers to let the client's desire and tolerance for activity determine the client's activity level.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? blood glucose level of 200 mg/dl (11.1 mmol/L) white blood cell (WBC) count of 20,000/mm3 (0.02 L) potassium level of 3.5 mEq/L (3.5 mmol/L) hematocrit (HCT) of 35%

white blood cell (WBC) count of 20,000/mm3 (0.02 L) Explanation: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

A 21-year-old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of discharge teaching? Select all that apply. "I will take acetaminophen for pain." "I do not need to inspect the puncture site." "I will not be able to play basketball for the next 2 days." "I will take aspirin if I have pain." "I can apply an ice pack or a cold compress to the puncture site."

"I will take acetaminophen for pain." "I will not be able to play basketball for the next 2 days." "I can apply an ice pack or a cold compress to the puncture site." Explanation: Acetaminophen is a safer analgesic than aspirin in order to avoid bleeding. Contact sports or trauma to the site should be avoided. Cool compresses should limit swelling and bruising. The puncture site should be inspected every 2 hours for bleeding or bruising during the first 24 hours.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply. Pain medication has been administered orally and was effective. This is a severe burn and nerve endings have been destroyed. This is a superficial burn, so no pain is present. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

-This is a severe burn and nerve endings have been destroyed. -The child must be monitored for signs of fluid shift. -Rehabilitation and skin grafting will be necessary. Explanation: This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported immediately to a burn center for treatment? Select all that apply. an 8-year-old with third-degree burns over 10% of the body surface area (BSA) a 20-year-old who inhaled the smoke of the fire a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) a 30-year-old with second-degree burns on the back of the left leg (about 9% of body surface area (BSA) a 40-year-old with second-degree burns on the right arm (about 10% of BSA)

-an 8-year-old with third-degree burns over 10% of the body surface area (BSA) -a 20-year-old who inhaled the smoke of the fire -a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) Explanation: Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

A nurse is conducting a cancer risk screening program. Which client is at greatest risk for skin cancer? 45-year-old health care worker 15-year-old high school student 30-year-old butcher 60-year-old mountain biker

60-year-old mountain biker Explanation: Basal cell carcinoma occurs most commonly in sun-exposed areas of the body. The incidence of skin cancer is highest in older people who live in the mountains or spend outdoor leisure time at higher altitudes.

Which nursing goal is appropriate for the nurse to make with a client who has multiple myeloma? Achieve effective management of bone pain. Recover from the disease with minimal disabilities. Decrease episodes of nausea and vomiting. Avoid hyperkalemia.

Achieve effective management of bone pain. Explanation: In multiple myeloma, neoplastic plasma cells invade the bone marrow and begin to destroy the bone. As a result of this skeletal destruction, pain can be significant. There is no cure for multiple myeloma. Nausea and vomiting are not characteristics of the disease, although the client may experience anorexia. The client should be monitored for signs of hypercalcemia resulting from bone destruction, not for hyperkalemia.

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client? Anaphylaxis Acute respiratory distress syndrome (ARDS) Chronic obstructive pulmonary disease (COPD) Mitral valve prolapse

Acute respiratory distress syndrome (ARDS) Explanation: ARDS is a complication associated with sepsis. ARDS causes respiratory failure and may lead to death, even after the client has recovered from sepsis. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial air flow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first? Initiate gastric lavage. Maintain body temperature. Administer 100% oxygen by mask. Obtain a psychiatric referral.

Administer 100% oxygen by mask. Explanation: Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature, thus steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate.

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply. Administer Diphenhydramine. Insert an intravenous line. Give metoprolol. Have respiratory therapy provide an albuterol treatment. Monitor international normalized ratio (INR) level.

Administer Diphenhydramine. Insert an intravenous line. Have respiratory therapy provide an albuterol treatment. Explanation: Administering diphenhydramine reverses the effect of histamine. Inserting an intravenous line will allow access to administer medications quickly. Metoprolol is a medication used to treat hypertension or chest pain. Administering an albuterol treatment reverses histamine-induced bronchospasm. The international normalized ratio (INR) level is monitored for warfarin treatment.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. What is the priority intervention to maintain safety for this client? Maintain continuous fetal monitoring. Encourage family members to remain at bedside. Assess reflexes, clonus, visual disturbances, and headache. Monitor maternal liver studies every 4 hours.

Assess reflexes, clonus, visual disturbances, and headache. Explanation: The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised, and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system, but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

A client with diabetes mellitus gives birth to a 9-lb, 10-oz (4,375 g) neonate at 38 weeks. What is the nurse's priority action after the stabilization of the neonate? Assess the neonate's reflexes. Provide glucose solution to neonate. Assess the neonate's weight. Assess the neonate's blood glucose level.

Assess the neonate's blood glucose level. Explanation: Glucose monitoring of the neonate born to a mother with diabetes is essential because the neonate is at risk for developing hypoglycemia after birth. The nurse should not provide glucose until after the blood glucose level is known to determine if it is needed. It is not necessary to immediately assess weight or reflexes.

A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula. What intervention will the nurse include in the care plan? Apply lotion to the AV fistula daily. Clean the AV fistula with sterile saline. Palpate the AV fistula for a bruit. Auscultate the AV fistula for a bruit.

Auscultate the AV fistula for a bruit. Explanation: The nurse needs to auscultate the AV fistula for a bruit to assess for blood flow. The AV fistula does not require lotion for moisture. It also does not need to be cleaned with saline; it is intact skin except when it's being accessed for dialysis. The nurse will palpate the fistula for a thrill.

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply. Remind health care providers to draw blood from veins on the left side. Avoid sleeping on the left arm. Wear wrist watch on the right arm. Assess fingers on the left arm for warmth. Obtain blood pressure (BP) from the left arm.

Avoid sleeping on the left arm. Wear wrist watch on the right arm. Assess fingers on the left arm for warmth. Explanation: The nurse instructs the client to protect the site of the fistula. The client should avoid pressure on the involved arm such as sleeping on it, wearing tight jewelry, or obtaining BP. The client is also advised to assess the area distal to the fistula for adequate circulation, such as warmth and color. When the client is hospitalized, the nurse posts a sign on the client's bed not to draw blood or obtain BP on the left side; the client is also instructed to be sure that none of the health care team members do so.

A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to: combat inflammation. prevent infection. prevent platelet aggregation. promote diuresis.

combat inflammation. Explanation: Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would order antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics, not corticosteroids, promote diuresis.

A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include serum creatinine level 0.5 mg/dl (44.2 mcmol/L) serum calcium level of 7.5 mg/dl (1.9 mmol/L) Bence Jones protein in the urine serum protein level 5.8 g/dl (58 g/L)

Bence Jones protein in the urine Explanation: Presence of Bence Jones protein in the urine almost always confirms multiple myeloma; however, absence of the protein doesn't rule out the disease. Serum creatinine level may be increased (above 1.2 mg/dl in men and 0.9 mg/dl in women). Serum calcium levels are above 10.2 mg/dl (2.55 mmol/L) in multiple myeloma because calcium is lost from the bone and reabsorbed in the serum. The serum protein level is increased in multiple myeloma, not decreased.

A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client? Continuous fetal heart rate monitoring will be implemented. Frequent ultrasound examinations will be performed. At least 5 to 10 fetal scalp pH tests will be performed. Oligohydramnios will be carefully evaluated.

Continuous fetal heart rate monitoring will be implemented. Explanation: Uteroplacental insufficiency is associated with a postterm fetus; therefore, it is recommended that the fetal heart rate and contraction pattern be monitored throughout the labor and birth process. In addition, intravenous oxytocin, which is frequently used for induction of labor, may result in hyperstimulation of the uterus. Therefore, monitoring the client is critical.One ultrasound may be performed to assess position and confirm gestational age.A scalp pH may be performed if there is evidence of fetal bradycardia, late decelerations, and a possibility of fetal hypoxia. Even so, 5 to 10 scalp pH measurements would be highly unusual.Postterm clients generally do not have a decreased amount of amniotic fluid (oligohydramnios).

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)? Suction the airway every hour and as needed. Elevate the head of the bed 15 to 30 degrees. Turn the client and change their position every 2 hours. Maintain a well-lit room.

Elevate the head of the bed 15 to 30 degrees. Explanation: To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning the client from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.

A client is admitted to a healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? Activity intolerance related to shortness of breath Anxiety related to difficulty breathing Risk for infection related to retained secretions Impaired gas exchange related to airflow obstruction

Impaired gas exchange related to airflow obstruction Explanation: A patent airway and an adequate breathing pattern are the top priority for any client, making Impaired gas exchange related to airflow obstruction the most important nursing diagnosis. Although Activity intolerance, Anxiety and Risk for infection may also apply to this client, they aren't as important as Impaired gas exchange.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? Institute droplet precautions. Obtain the child's vital signs. Ask the parent about medication allergies. Inquire about the health of siblings at home.

Institute droplet precautions. Explanation: The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? It can be adjusted to a position of comfort. It is used to lift the child. It adds strength to the cast. It is necessary to turn the child.

It adds strength to the cast. Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast.

A client at 30 weeks gestation experiences a rupture of membranes with mild contractions 8 minutes apart. Which nursing interventions are included on the plan of care to improve newborn outcomes? Select all that apply. Maintain the client on the fetal monitor throughout the labor process. Administer a dose of betamethasone per healthcare provider's order. Arrange a neonatologist to be available for the birth. Ensure the mother remains nothing by mouth (NPO) throughout the labor. Position the mother in a supine position with the feet elevated. Begin an oxytocin drip once the mother reaches 3 cm dilated.

Maintain the client on the fetal monitor throughout the labor process. Administer a dose of betamethasone per healthcare provider's order. Arrange a neonatologist to be available for the birth. Explanation: The nurse caring for a client at 30 weeks gestation who has a rupture of membranes realizes that preparation is needed for a premature delivery. To improve newborn outcomes, the nurse must be aware of the status of the fetus via a fetal monitor, administer betamethasone (it is best to have at least two doses 12 hours apart) to increase the surfactant level and fetal lung maturity, and have resuscitation equipment available, if needed. It is best have a neonatologist present as well to assess the neonate and plan medical care. The mother typically is permitted to have ice chips at most in case emergency surgery is needed. The mother is not placed in a supine position as there is the potential of compressing the vena cava causing maternal hypotension and reduced blood flow to the fetus. Oxytocin is naturally produced by the posterior pituitary with Pitocin being the synthetic version. It is used to stimulate contractions. Stimulating contractions is not indicated at this time.

What is the most important goal of nursing care for a client who is in shock? Manage fluid overload. Manage increased cardiac output. Manage inadequate tissue perfusion. Manage vasoconstriction of vascular beds.

Manage inadequate tissue perfusion. Explanation: Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? Place an indwelling catheter. Monitor fetal heart tones. Perform a cervical examination. Prepare the client for cesarean birth.

Monitor fetal heart tones. Explanation: Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.

Umbilical cord prolapse occurs after spontaneous rupture of the membranes. What should the nurse do immediately? Place the client in a Trendelenburg position. Administer oxytocin intravenously. Ask the client to begin pushing. Cover the cord with sterile towels.

Place the client in a Trendelenburg position. Explanation: The first step in managing a cord prolapse is to relieve pressure on the cord. Immediate measures include lowering the client's head by using the Trendelenburg position or knee-to-chest position so that the fetal presenting part will move away from the pelvis and moving the fetal presenting part off the cord by applying pressure through the vagina with a sterile gloved hand. An immediate cesarean birth is usually performed.Oxytocin would not be given because the drug stimulates uterine contractions, putting further pressure on the cord as the contractions attempt to expel the fetus.Pushing results in further cord compression and decreased fetal heart rate.With cord prolapse, an immediate cesarean birth is indicated. There is no need to cover the cord to avoid damage or tearing.

A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made after the procedure would indicate the development of a potential complication? The client has a sore throat. The client displays signs of sedation. The client experiences a sudden increase in temperature. The client demonstrates a lack of appetite.

The client experiences a sudden increase in temperature. Explanation: The most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the health care provider.A sore throat is to be anticipated after an endoscopy.Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed.A lack of appetite could be the result of many factors, including the disease process.

During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room? a prayer book a picture a bouquet of flowers a hairbrush

a bouquet of flowers Explanation: The induction phase of chemotherapy is an aggressive treatment to kill leukemia cells. The client is severely immunocompromised and severely at risk for infection. Flowers, herbs, and plants should be avoided during this time. The client's prayer book, pictures, and other personal belongings can be cleaned before being brought into the room to prevent client contact with pathogenic and nonpathogenic organisms.

The care of which client can be assigned to an unlicensed assistive personnel (UAP)? a client with stomatitis who requires instruction about mouth care before discharge a client who is having radiation for cancer of the stomach and is to have the radiation site bathed with warm water, followed by an application of a moisturizer a client who had a gastric resection and has a nasogastric tube draining bright red blood a client who had abdominal surgery and requires wet-to-dry dressing changes

a client who is having radiation for cancer of the stomach and is to have the radiation site bathed with warm water, followed by an application of a moisturizer Explanation: The care of the client who is having radiation treatments and requires skin care at the site that involves bathing and application of a nonmedicated moisturizer is within the scope of practice for the UAP. Discharge planning, assessing drainage, and changing wet-to-dry dressings are nursing care activities that must be performed by a licensed nurse.

Which client is the most appropriate candidate for whom the nurse would assist in coordinating hospice services? a client with lung cancer and a 3- to 4-month life expectancy a client with newly diagnosed breast cancer undergoing chemotherapy and radiation therapy a client on hemodialysis who works as a schoolteacher a client with Guillain-Barré undergoing plasmapheresis

a client with lung cancer and a 3- to 4-month life expectancy Explanation: The client with lung cancer and a 3- to 4-month life expectancy is a candidate for hospice care, which provides support and services to dying clients and their families. The client with breast cancer is undergoing treatment and is not a candidate for hospice. An active hemodialysis client and a client seeking treatment for Guillain-Barré are also not candidates for hospice care.

A nurse is caring for a client who is receiving chemotherapy for lung cancer. During the hand-off report, the nurse from the previous shift states that the client has been placed on neutropenic precautions. Which laboratory value supports this nursing action? a red blood cell count of 3.5 million/mm3 a platelet count of 90,000 per microliter a retculocyte count of 1% a white blood cell count of 2200/mm3

a white blood cell count of 2200/mm3 Explanation: The normal number of WBCs in the blood is 4,500-10,000 white blood cells per microliter (mcL). Less than 4,500 is considered neutropenia and places the client at risk for infection. The platelet count ranges from 150,000 to 450,000/mcL. Platelets are responsible for blood clotting. The nurse needs to institute bleeding precautions for this, not neutropenic precautions. Red blood cells are responsible for oxygen transport. The reticulocyte count is normal.

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.

At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate? risk for injury related to rapid delivery acute pain related to wearing off of anesthesia hyperthermia related to effects of anesthesia altered tissue perfusion related to effects of anesthesia

altered tissue perfusion related to effects of anesthesia Explanation: A disadvantage of lumbar epidural is the risk for hypotension, which can lead to altered tissue perfusion. Epidurals are associated with longer labor and hypothermia, not rapid delivery and hyperthermia. Any pain the client experiences wouldn't be directly related to the wearing off of anesthesia.

An older adult client experiencing anaphylaxis is administered intramuscular epinephrine. For what adverse effect(s) of epinephrine will the nurse assess? Select all that apply. angina hypertension bradycardia oliguria bronchoconstriction

angina hypertension oliguria Explanation: Epinephrine is a nonselective alpha and beta adrenergic agonist. By activating the sympathetic nervous system it produces vasoconstriction, which helps reverse the hypotension of anaphylactic shock and can produce hypertension. It also increases heart rate and can induce angina for those at risk. Due to renal arteriole vasoconstriction, decreased urine output may occur. The stimulation of beta 2 receptors results in bronchodilation, which reverses the bronchoconstriction experienced in anaphylaxis and improves oxygenation.

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? oxygen saturation level arterial blood gas (ABG) findings red blood cells (RBCs) and hemoglobin count findings white blood cell differential

arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? fluid intake for the past 24 hours baseline arterial blood gas (ABG) levels prior outcomes of weaning electrocardiogram (ECG) results

baseline arterial blood gas (ABG) levels Explanation: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

A client who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply. fetal lung maturity gestational diabetes chromosomal defects neural tube defects polyhydramnios sex of the fetus

chromosomal defects neural tube defects sex of the fetus Explanation: In early pregnancy, amniocentesis can be used to identify chromosomal and neural tube defects and to determine the sex of the fetus. It can also be used to evaluate fetal lung maturity during the last trimester of pregnancy. According to the US Preventive Health Task Force, a blood test performed after 24 weeks of gestation is used to screen for gestational diabetes. Ultrasound is used to identify polyhydramnios; amniocentesis can be used to treat polyhydramnios by removing excess fluid.

Which outcome is expected of a nursing referral to a cancer support group? The client can: choose the best treatment options. find financial help. obtain home health care. cope with cancer.

cope with cancer. Explanation: Support groups are designed to educate clients and their families experiencing cancer about the disease and methods of coping positively with it. These are self-help and support groups monitored by professionals and cancer survivors who have undergone a training course that helps them to facilitate small groups.

The end of the third stage of labor is marked by what event? the birth of the neonate complete dilation delivery of the placenta transfer of the client to the postpartum bed

delivery of the placenta Explanation: The third stage of labor is marked by the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 2 hours after birth.

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member? social worker staff nurse clinical educator enterostomal nurse

enterostomal nurse Explanation: The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

Before surgery to remove an ectopic pregnancy and the fallopian tube, which sign or symptom would alert the nurse to the possibility of tubal rupture? amount of vaginal bleeding and discharge falling hematocrit and hemoglobin levels slow, bounding pulse rate of 80 bpm marked abdominal edema

falling hematocrit and hemoglobin levels Explanation: Diaphoresis, or profuse sweating, indicates shock, which occurs if the tube ruptures. Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain, referred shoulder pain, and falling blood pressure. The amount of vaginal bleeding that is evident is a poor estimate of actual blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse. Abdominal edema is a late sign of a tubal rupture in ectopic pregnancy.

The nurse is performing a breast examination on a client. Which findings most strongly suggest that a client has breast cancer? asymmetry of breasts, clear discharge from nipple fixed nodular mass, breast pain, dimpling of the skin bloody discharge from nipple, multiple movable masses, pain swollen axilla lymph nodes, fever, and fatigue

fixed nodular mass, breast pain, dimpling of the skin Explanation: A fixed nodular mass with dimpling of the overlying skin is the most significant sign of breast cancer. This is common during the late stages of breast cancer. Breast pain may be associated with cancer, but may also be related to a benign condition. Many women have asymmetrical breasts. Nipple discharge, whether bloody or clear, maybe a sign of cancer, but are also commonly associated with benign conditions and are not the most significant sign of cancer. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. Although metastasis to lymph nodes may occur, fever is not a typical finding of breast cancer.

The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition? good fair poor critical

good Explanation: The Apgar rating system evaluates the neonate on the basis of heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1- and 5-minute intervals after birth. The neonate receives a score between 0 and 10. The higher the score, the better the neonate's condition. Scores between 7 and 10 indicate good status. An Apgar score between 4 and 6 indicates fair condition with a possible need for oxygen, suction, and stimulation.An Apgar score between 0 and 3 is indicative of poor neonatal status and a need for resuscitation. This status is also sometimes referred to as critical.

A client makes a routine visit to the prenatal clinic. Although the client is 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.

A client had a right pneumonectomy for lung cancer yesterday and now has dyspnea. What position in bed will be best for this client? lying on the left side positioned for postural drainage head of bed elevated flat in bed on full bed rest

head of bed elevated Explanation: The client will be most comfortable and have the best lung expansion with the head of the bed elevated. When in a side lying position, the client should lie on the right side to permit expansion of the unaffected lung. Postural drainage positioning will lower the head of bed and increase dyspnea. Lying flat will increase the dyspnea; the client should be encouraged to be out of bed as tolerated.

A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position? high Fowler's side-lying prone supine

high Fowler's Explanation: The goal of the intervention is to decrease the child's work of breathing by decreasing pressure on the diaphragm and increase chest expansion by increasing the pull of gravity on the diaphragm. Placing the client in high Fowler's position accomplishes this. Side-lying positions make it more difficult to expand the side of the lung closest to the bed. The prone or supine position does not decrease the work of breathing unless the head of the bed is raised.

A client, age 42, visits the gynecologist. After examining the client, the healthcare provider suspects cervical cancer. What will be most important for the nurse to include in assessing the client's health history? the onset of sexual activity smoking history diet and exercise history of human papillomavirus infection

history of human papillomavirus infection Explanation: The nurse would assess for risk factors associated with cervical cancer. The most important risk factor for cervical cancer is human papillomavirus infection. The onset of sexual activity may indirectly increase the risk of cervical cancer. Smoking is a risk factor for cervical cancer but not the most important one. Diet and exercise are not important risk factors for cervical cancer.

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse? hypothermia tachycardia bradypnea hypoxia

hypothermia Explanation: The neonate's normal axillary temperature should range from approximately 97.7°F to 99.5°F (36.5°C to 37.5°C). A temperature of 95.5°F (35.3°C) is very low. When the temperature drops, the neonate is at risk for hypothermia, respiratory distress, and hypoglycemia. The normal respiratory rate for a newborn is 30 to 60 breaths/minute while resting. It can increase with crying, and it will increase if hypothermia develops. This neonate would have tachypnea instead of bradypnea. The normal heart rate for a newborn is 110 to 160 beats/minute, so 110 beats/minute would be a normal finding and not tachycardia. All neonates have acrocyanosis of the hands and feet in the first few hours of life; this would not indicate hypoxia.

A client has malignant lymphoma. As part of their chemotherapy, the physician orders an alkylating drug. When caring for the client, the nurse teaches the client about adverse reactions to alkylating drugs. The nurse tells the client that they might begin to see adverse reactions immediately. in 1 week. in 2 to 3 weeks. in 1 month.

in 2 to 3 weeks. Explanation: The nurse should tell the client that they might see adverse reactions, such as alopecia, 2 to 3 weeks after starting therapy with an alkylating drug.

A woman tells the nurse, "There has been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer? pain leg edema urinary and rectal symptoms light bleeding or watery vaginal discharge

light bleeding or watery vaginal discharge Explanation: In its early stages, cancer of the cervix is usually asymptomatic, which underscores the importance of regular Pap smears. A light bleeding or serosanguineous discharge may be apparent as the first noticeable symptom. Pain, leg edema, urinary and rectal symptoms, and weight loss are late signs of cervical cancer.

A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment? sedation hyperbilirubinemia low birth weight hypocalcemia

low birth weight Explanation: Neonates born to mothers who smoke tend to have lower-than-average birth weights. Neonates born to mothers who smoke also are at higher risk for stillbirth, sudden infant death syndrome, bronchitis, allergies, delayed growth and development, and polycythemia. Maternal smoking is not related to higher neonatal sedation, hyperbilirubinemia, or hypocalcemia. Smoking may cause irritability, not sedation. Hyperbilirubinemia is associated with Rh or ABO incompatibility or the administration of intravenous oxytocin during labor. Approximately 50% of neonates born to mothers with insulin-dependent diabetes experience hypocalcemia during the first 3 days of life.

A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which medication may be prescribed? progestin contraceptives medroxyprogesterone methotrexate dyphylline

methotrexate Explanation: Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by leucovorin. This chemotherapeutic agent attacks the fast-growing zygote and trophoblast cells. RU-486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine whether the tube is still patent. Progestin-only contraceptives and medroxyprogesterone are ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used.

After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which as an adverse effect? weight gain nausea headache ovarian cancer

ovarian cancer Explanation: The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovarian and endometrial cancers are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is thrombophlebitis.

A client has been in early labor, with contractions every 10 to 12 minutes, for the past 12 hours with no progression. What medication should the nurse anticipate to help stimulate this client's uterine contractions? estrogen magnesium sulfate oxytocin terbutaline

oxytocin Explanation: Oxytocin is the hormone responsible for stimulating uterine contractions. Pitocin, the synthetic form, has similar action, and may be given to some clients to induce or augment uterine contractions. Although estrogen plays a role in uterine contractions, it is not given in synthetic form to help uterine contractility. Progesterone has a relaxing effect on the uterus. Magnesium sulfate is used for maternal preeclampsia. It is not a tocolytic agent.

When the nurse is assessing a 34-year-old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which symptom would most likely alert the nurse that placenta previa is present? painless vaginal bleeding uterine tetany intermittent pain with spotting dull lower back pain

painless vaginal bleeding Explanation: The most common assessment finding associated with placenta previa is painless vaginal bleeding. With placenta previa, the placenta is abnormally implanted, covering a portion or all of the cervical os. Uterine tetany, intermittent pain with spotting, and dull lower back pain are not associated with placenta previa. Uterine tetany is associated with oxytocin administration. Intermittent pain with spotting commonly is associated with a spontaneous abortion. Dull lower back pain is commonly associated with poor maternal posture or a urinary tract infection with renal involvement.

A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused and reports minor pain. When assessing the client, which is an immediate priority for the nurse to evaluate? integrity of the oral mucosa ability to swallow tone and quality of speech patency of airway

patency of airway Explanation: It is very likely that the client has had a smoke inhalation injury after suffering a severe burn greater than 20% of the total body surface area and having burns of the face and neck. The carbon particles observed around the nose and mouth would support this. Smoke inhalation can cause severe injury to the upper airway and lead to death. The integrity of the oral mucosa would be appropriate if the client is experiencing mouth pain. The ability to swallow might be applicable if the client is experiencing neck swelling. The tone and quality of speech would be related to the inhalation injury, but they can be evaluated once an adequate airway is validated.

A primigravid client is experiencing a prolonged second stage of labor with a fetus suspected of weighing more than 4 kg. Which intervention is most important? preparing for a vacuum-assisted delivery administering an IV fluid bolus preparing for an emergency cesarean birth performing the McRoberts maneuver

performing the McRoberts maneuver Explanation: A prolonged second stage of labor with a large fetus could indicate a shoulder dystocia at birth. Immediate nursing actions for a shoulder dystocia include suprapubic pressure and the McRoberts maneuver. If after interventions for vaginal birth with a shoulder dystocia fail, an emergency cesarean birth may be needed but is not indicated at this time. A vacuum-assisted birth would be contraindicated due to increased risk of shoulder dystocia with a macrosomic infant. An IV fluid bolus may be indicated for fetal distress, but there is not enough information to establish that they are needed at this time.

A nurse is interviewing a client about their past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? duodenal ulcers hemorrhoids weight gain polyps

polyps Explanation: Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

The nurse is caring for a child with a new diagnosis of diabetes. The nurse teaches blood glucose monitoring by allowing the child to practice checking the blood sugar of a toy bear dressed in a hospital gown. The nurse recognizes this approach to be appropriate for what age level? preschool age (3 to 5 years) adolescence (10 to 19 years) school age (5 to 10 years) toddler (1 to 3 years)

preschool age (3 to 5 years) Explanation: Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play, and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible.

Which nursing intervention is most appropriate for a client with multiple myeloma? monitoring respiratory status balancing rest and activity restricting fluid intake preventing bone injury

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

A 16-year-old unmarried client visiting the prenatal clinic at 32 weeks' gestation and currently weighing 140 lb (63.5 kg) is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inch (158 cm) tall and weighed 120 lb (54.4 kg) before the pregnancy. Which factor would be most important to assess? proteinuria small-for-gestational-age fetus ABO incompatibility fluid intake

proteinuria Explanation: Because the client is being closely monitored for early signs of preeclampsia, checking the urine for proteinuria is most important. Proteinuria, even in the absence of an elevated blood pressure, is indicative of preeclampsia.Although adolescent pregnancy is associated with an increase in the number of small-for-gestational-age fetuses, this is not indicative of preeclampsia.ABO incompatibility, occurring when the mother has type O blood and the fetus is type A, B, or AB blood, is not associated with preeclampsia. Fluid intake is an important assessment for any pregnant client.However, it is not a primary indication of preeclampsia. Edema of the hands and face is a more important indicator than fluid intake.

A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. During the second postoperative day, which assessment finding requires immediate intervention? abdominal pain hypoactive bowel sounds serous drainage from the incision shallow breathing and increasing lethargy

shallow breathing and increasing lethargy Explanation: Shallow breathing and a change in the level of consciousness, such as increasing lethargy requires immediate intervention because they may indicate a respiratory complication — for example, atelectasis or carbon dioxide retention. To avoid respiratory complications, the nurse should encourage turning, coughing, deep breathing, and ambulation during the early postoperative period. Abdominal pain, hypoactive bowel sounds, and serous drainage from the incision are expected findings during the first few days after this type of surgery.

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings may signify: infection. umbilical cord prolapse. start of the second stage of labor. need for labor induction.

umbilical cord prolapse. Explanation: After an amniotomy, a significant change in the FHR, particularly large variable decelerations associated with cord compression, may indicate umbilical cord prolapse. This movement of the umbilical cord relative to the fetal presenting part is an obstetric emergency that requires immediate intervention to prevent fetal hypoxia. Infection, the start of the second stage of labor, and the need for labor induction aren't associated with FHR changes. An infection causes temperature elevation. The second stage of labor starts with complete cervical dilation. Labor induction is indicated if the client's labor fails to progress.

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? unequal pupil size decreasing systolic blood pressure tachycardia decreasing body temperature

unequal pupil size Explanation: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply. flexion of the arms and wrists with internal rotation. wrist pronation. stiff extension of the arms and legs. plantar flexion of the feet. opisthotonos.

wrist pronation. stiff extension of the arms and legs. plantar flexion of the feet. opisthotonos. Explanation: Decerebrate posture, which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.

The nurse is caring for a client who possibly may need kidney dialysis. When evaluating the client's renal function to report to the health care provider, which data will the nurse use? Select all that apply. 24-hour urinary output glomerular filtration rate trending vital signs flank pain level blood count report serum creatinine level

24-hour urinary output glomerular filtration rate serum creatinine level Explanation: When evaluating renal functioning, the nurse would report to the health care provider information on the client's current urine output, the glomerular filtration rate, and serum creatinine levels that identify the degree of kidney dysfunction. This objective data provides diagnostic information. Vital signs and pain level reflect the impact of the renal disease. Blood count reports to do not assist in evaluating renal function.

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage.

A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed.

A client with an uncomplicated term pregnancy arrives at the labor-and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action? Prepare the woman for birth. Ask what time this happened and note the color, amount, and odor of the fluid. Immediately contact the provider. Collect a sample of the fluid for microbial analysis.

Ask what time this happened and note the color, amount, and odor of the fluid. Explanation: Gather more information. Noting the color, amount, and odor of the fluid, as well as the time of rupture, will help guide the nurse in the next action. There's no need to immediately call the client's provider or prepare this client for birth if the fluid is clear and birth isn't imminent. Rupture of membranes isn't unusual in the early stages of labor. Fluid collection for microbial analysis is not routine if there's no concern for infection.

What should the nurse do first when admitting a toddler with croup? Monitor vital signs. Assess respiratory status. Ensure adequate fluid intake. Place a tracheostomy set at the bedside.

Assess respiratory status. Explanation: For the child with croup, assessing the child's respiratory status is the priority. It is especially important to assess airway patency because laryngeal spasms can occur suddenly. After the nurse has assessed the toddler's respiratory status, having a tracheostomy set at the bedside would be the next priority. Monitoring vital signs is important, as is ensuring adequate fluid intake to keep secretions loose, but assessing respiratory status is key.

A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first? Increase the rate of the oxytocin infusion. Turn the client to a knee-to-chest position. Assess cervical dilation and effacement. Assess the fetal heart rate.

Assess the fetal heart rate. Explanation: Assessing the fetal heart rate is always a priority after spontaneous rupture of membranes has occurred. Meconium-stained fluid is also a common sign of fetal distress related to an inadequate transfer of oxygen to the fetus. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (e.g., late decelerations), the health care provider (HCP) should be notified immediately. A cesarean birth may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the client to the left side, rather than a knee-chest position, improves placental perfusion. The HCP may wish to determine the extent of cervical dilation to make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate monitoring is essential to determine fetal status.

The primary care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding? The client is sedated. There is increased placental perfusion. There is improvement in fetal lung function. Contractions cease.

Contractions cease. Explanation: Tocolytics are used to stop uterine contractions. Sedation is not its purpose of a tocolytics. Tocolytics have no effect on placental perfusion or the fetal pulmonary system or lung function.

A client diagnosed with chronic renal failure is undergoing hemodialysis. Post dialysis, the client weighs 59 kg. The nurse should teach the client to make which dietary changes? Increase sodium in the diet to 4 g/day. Limit the total number of calories consumed each day to 1,000. Increase fluid intake to 3,000 mL each day. Control the amount of protein intake to 59 to 70 g/day.

Control the amount of protein intake to 59 to 70 g/day. Explanation: Hemodialysis clients have their protein requirements individually tailored according to their post-dialysis weight. The protein requirement is 1.0 to 1.2 g/kg body weight per day. Hence, for a 59-kg weight, the amount of protein will be 59 to 70 g/day. Sodium should be restricted to 3 g/day. The 1,000 calories a day is not sufficient; if calories are not supplied in adequate amount, the body will use tissue protein for energy, which will lead to a negative nitrogen balance and malnutrition. Fluid intake needs to be restricted to 500 to 700 mL plus the urine output.

Which approach would be the most therapeutic when working with the parent of a client presenting with quadriplegia as a result of a C-5 spinal cord injury? Reassure that given time and motivation prior level of functional ability will return. Advise that being this upset is not in the client's best interest. Explain the importance of moral support. Encourage the parent to express feelings and other fears about the injury.

Encourage the parent to express feelings and other fears about the injury. Explanation: Listening and encouraging the client's parent to express feelings will be most therapeutic and will allow the nurse to gather more data about understanding the injury. The other choices are not reflected in therapeutic response.

The nurse is receiving shift report on four clients on an antenatal unit. The four clients are: (1) a 35-week-gestation mother with severe preeclampsia started on a maintenance dose of magnesium sulfate 1 hour ago; (2) a 30-week-gestation client with preterm labor on an oral tocolytic and having no contractions in 6 hours; (3) a hyperemesis client with emesis 4 times in the past 12 hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. Which action should the nurse take first? Evaluate the client with preeclampsia for maternal and fetal tolerance of magnesium sulfate and the labor pattern. Assess the client with preterm labor for tolerance of tocolytics and the labor pattern. Assess the hyperemesis client for nausea for further emesis, or dehydration. Evaluate the placenta previa client without an exam.

Evaluate the placenta previa client without an exam. Explanation: The first action taken should be to evaluate the placenta previa client who has pelvic pressure. The pelvic pressure may be caused by a fetal head creating pressure in the pelvis indicating a potential birth. This client should be evaluated without a pelvic exam and then consult with the health care provider (HCP). A vaginal exam is contraindicated as it may stimulate bleeding of the placenta. The second action would be to complete an assessment on the client with preeclampsia and her fetus to evaluate for tolerance and effectiveness of the magnesium sulfate. The hyperemesis client needs to be evaluated for hydration status and for medication. The preterm labor client is stable on the oral medication and should be seen last.

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first? Assist the client to a stretcher. Hold pressure on the fetal head. Take the client to the labor and delivery unit. Notify the healthcare provider.

Hold pressure on the fetal head. Explanation: A prolapsed cord is an emergency situation. The most important function for the nurse is to hold pressure on the fetal head to decrease pressure on the cord and prevent further fetal compromise. While holding pressure, the nurse can call for help to assist the client to a stretcher and have someone notify the healthcare provider. Once this is done, the labor and delivery unit will be notified so that an operating room is ready for a cesarean delivery. The nurse should maintain pressure on the fetal head throughout the process to prevent occlusion of the umbilical cord.

When planning to move a person with a possible spinal cord injury, the nurse should direct the team to move the client using which procedure? Limit movement of the arms by wrapping them next to the body. Move the person gently to help reduce pain. Immobilize the head and neck to prevent further injury. Cushion the back with pillows to ensure comfort.

Immobilize the head and neck to prevent further injury. Explanation: The priority concern is to immobilize the head and neck to prevent further trauma when a fractured vertebra is unstable and easily displaced. Although wrapping and supporting the extremities is important, it does not take priority over immobilizing the head and neck. Pain usually is not a significant consideration with this type of injury. Cushioning is contraindicated. The neck should be kept in a neutral position and immobilized. Flexion of the neck is avoided.

What is the function of cerebrospinal fluid (CSF)? It cushions the brain and spinal cord. It acts as an insulator to maintain a constant spinal fluid temperature. It acts as a barrier to bacteria. It produces cerebral neurotransmitters.

It cushions the brain and spinal cord. Explanation: CSF is produced primarily in the lateral ventricles of the brain. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue. CSF doesn't act as an insulator or a barrier and it doesn't produce cerebral neurotransmitters.

A client tells the nurse that her bra fits more snugly at certain times of the month and she is concerned this may be a sign of breast cancer. The nurse should give the client which information about this situation? A change in breast size should be checked by her health care provider (HCP). Benign cysts tend to cause the breast to vary in size. It is normal for the breast to increase in size before menstruation begins. A difference in the size of her breasts is related to normal growth and development

It is normal for the breast to increase in size before menstruation begins. Explanation: Normally, breasts are about the same size. They can vary in size before menstruation due to breast engorgement caused by hormonal changes. It is not necessary for a HCP to check this slight change in breast size. The changes in breast size this client described are most likely caused by hormonal changes, not a benign cyst or normal growth and development.

A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury? Turn and reposition every 2 hours. Maintain proper alignment. Maintain a patent airway. Monitor vital signs.

Maintain a patent airway. Explanation: Initial care is focused on establishing and maintaining a patent airway and supporting ventilation. Innervation to the intercostal muscles is affected; if spinal edema extends to the C4 level, paralysis of the diaphragm usually occurs. The effects and extent of edema are unpredictable in the first hours, and respiratory status must be closely monitored. Suction equipment should be readily available.Monitoring vital signs, maintaining proper alignment, and turning and positioning are important, but the priority nursing intervention is maintaining a patent airway.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? Pad the side rails. Place a pillow under the left buttock. Insert a padded tongue blade into the mouth. Maintain a patent airway.

Maintain a patent airway. Explanation: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure.Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure.Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.

What should the nurse include in the plan of care for a client with diabetes who is in labor? Measure urine output every 4 hours. Administer insulin subcutaneously every 4 hours. Check deep tendon reflexes every 2 hours. Monitor blood glucose levels every hour.

Monitor blood glucose levels every hour. Explanation: Because metabolic changes occur during labor and birth, close monitoring of the diabetic client's blood glucose level every hour during labor is necessary.There is no indication that the client's urine output needs to be measured every 4 hours.The need for insulin administration is determined by the client's blood glucose levels. If needed, insulin is usually given intravenously.Checking deep tendon reflexes would be necessary if the client had preeclampsia. However, because pregnant clients with diabetes are at higher risk for developing preeclampsia, any evidence of protein in the urine should be reported.

The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? Get used to some pain, and use a little less medication than needed to keep from being addicted. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Take analgesics only when pain returns. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain.

Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Explanation: The regular administration of analgesics provides a consistent serum level of medication, which can help prevent breakthrough pain. Therefore, taking the prescribed analgesics on a regular schedule is the best way to manage chronic cancer-related pain. There is little risk for the client with cancer-related pain to become addicted. Sleeping 12 to 16 hours a day would not allow the client to participate in usual daily activities or preferred activities.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)? Place the client in a jacket restraint. Wrap the hands in soft "mitten" restraints. Tuck the arms and hands under the sheet. Apply a wrist restraint to each arm.

Wrap the hands in soft "mitten" restraints. Explanation: It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the sheet restrict movement and add to feelings of being confined, all of which would add to the agitation and increase ICP.

A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up? The client has gained 10 lb (4.5 kg) over the past year. The client reports knee pain upon rising. The client reports a feeling of a lump in the throat. The client has a blood pressure of 135/80 mmHg and a pulse rate of 70 beats/minute.

The client reports a feeling of a lump in the throat. Explanation: The sensation of a lump in the throat is one of the warning signs of esophageal cancer and requires immediate follow-up. Other symptoms of esophageal cancer include dysphagia, substernal pain, regurgitation of undigested food, foul breath, and hiccups. A weight gain of 10 lb in a year, a blood pressure of 135/80 mmHg, and a pulse rate of 70 beats/minute are normal findings. Although the nurse should ultimately investigate the complaint of pain in the knees upon rising, this finding isn't the priority at this time.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk? a 20-year-old Asian woman a 30-year-old White man a 50-year-old Hispanic woman a 60-year-old Black man

a 60-year-old Black man Explanation: Multiple myeloma is more common in middle-aged and older adult clients. The median age at diagnosis is 60 years. It is twice as common in Black clients as it is in White clients, and it occurs most often in Black men.

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? a client at 13 weeks' gestation who is experiencing nausea and vomiting three times a day with + 1 ketones in her urine a client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain a primigravida at 17 weeks' gestation who reports not feeling fetal movement at this point in her pregnancy

a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain Explanation: A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at 13 weeks' gestation with nausea and vomiting is a concern because the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the insulin-dependent diabetic. The insulin-dependent diabetic is a high priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need additional testing to further evaluate fetal well-being.) The client who is at 17 weeks' gestation may be too early in her pregnancy to experience fetal movement and would be the last person to be seen.

Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy? abdominal pain, vaginal bleeding, and a positive pregnancy test nausea and vomiting amenorrhea and a negative pregnancy test copious discharge of clear mucous and prolonged epigastric pain

abdominal pain, vaginal bleeding, and a positive pregnancy test Explanation: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur before rupture, but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate a metabolic disorder such as hypothyroidism. Discharge of clear mucous isn't indicative of an ectopic pregnancy and referred shoulder pain, not epigastric pain, is expected.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately? oxygen saturation of 70 % on room air increased fremitus absent breath sounds on the affected side pain on the affected side of 6 on a scale of 1 to 10 when the client breathes

absent breath sounds on the affected side Explanation: Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds and is indicative of a pneumothorax. The nurse should notify the health care provider. An oxygen saturation of 70 percent is expected when a client has a crushing chest injury. Fremitus is a sign of increased lung consolidation. Moderate to severe pain is an expected finding following a crushing chest injury.

The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommend to women age 50 and older? annual self breast examination annual mammogram annual test for hormonal receptor assay biennial clinical breast examination by a healthcare provider

annual mammogram Explanation: The Canadian Cancer Society states at 50 years that women should have a mammogram annually and a clinical examination at least annually (not every 2 years). The American Cancer Society recommends mammography yearly beginning at age 40. All women should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen or progesterone dependent. An annual breast exam by a healthcare provider should be performed.

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis? seizure disorder chronic obstructive pulmonary disease (COPD) anemia bleeding disorder

bleeding disorder Explanation: A bleeding disorder is a contraindication for thoracentesis because a hemorrhage may occur during or after this procedure, possibly causing death. Although a history of a seizure disorder, COPD, or anemia calls for caution, it doesn't contraindicate thoracentesis.

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order? intravenous dextrose in water at 75 mL/hour vital signs every 4 hours blood chemistry of serum lactate blood chemistry of AST, alkaline phosphates TAKE A PRACTICE QUIZ

blood chemistry of serum lactate Explanation: Measuring blood chemistry of lactate can indicate sepsis. Lactate is a byproduct of ineffective cellular metabolism. The other answers are incorrect because dextrose is not a fluid volume expander and the rate is too low. Vitals would be monitored more frequently in sepsis. The other lab values are liver function tests.

A client is receiving oxytocin to induce labor. Which assessment findings indicate common adverse reactions? Select all that apply. blood pressure increased from baseline uterine tetany jaundice heart rate decreased from baseline variable decelerations

blood pressure increased from baseline uterine tetany variable decelerations Explanation: Common adverse reactions to oxytocin include hypertension, tachycardia, uterine tetany and hypertonicity, and variable decelerations. Oxytocin does not cause jaundice. Tachycardia, not decreased heart rate, is a common adverse reaction.

A nurse is caring for a client receiving I.V. magnesium sulfate. Which drug is the antidote for magnesium toxicity? calcium gluconate hydralazine/hydralazine naloxone Rohm(D) immune globulin

calcium gluconate Explanation: The nurse should anticipate administering 10 ml of 10% calcium gluconate by I.V. push over 3 to 5 minutes as a calcium gluconate antidote for magnesium toxicity. Hydralazine/hydralazine is given for sustained elevated blood pressures in clients with preeclampsia. Naloxone is used to correct opioid toxicity. Rohm(D) immune globulin is given to clients with Rh-negative blood to prevent antibody formation from Rh-positive fetuses.

The client with leukemia presents to the IV therapy clinic for chemotherapy. The nurse asks the client to roll up a sleeve to look for an IV access site. Which vein can the nurse access for this therapy? Select all that apply. antecubital cephalic dorsalis pedis antebrachial basilic

cephalic antebrachial basilic Explanation: The preferred sites are the basilic, antebrachial, and cephalic areas. The dorsalis pedis is a pulse site, and the antecubital is at the bend of the arm, making this site unfavorable for a caustic medication.

The nurse provides care to a client with anogenital warts. The nurse teaches that anogenital warts increase an adolescent female's risk of which condition? infertility cervical cancer dysmenorrhea urinary tract infections

cervical cancer Explanation: Anogenital warts are associated with human papillomavirus (HPV) and increase an adolescent female's risk of cervical cancer. This risk mandates treatment of all external lesions. HPV doesn't increase the risk of infertility, infections, or painful menstrual cycles.

When caring for the neonate weighing 4,564 g (10 lb, 1 oz) born vaginally to a woman with diabetes, the nurse should assess the neonate for fracture of which area? clavicle skull wrist rib cage

clavicle Explanation: Infants born to mothers with diabetes tend to be larger than average, and this neonate weighs 10 lb, 1 oz (4,564 g). The most common fractures are those of the clavicle and long bones, such as the femur. In a neonate, the skull bones are not fused and move to allow for vaginal birth, so skull fracture is rarely seen. Wrist and rib cages are rarely fractured.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to remove the raised skin because the blister has already broken. wash the area with soap and water to disinfect it. apply a weakened alcohol solution to clean the area. clean the area with normal saline solution and cover it with a protective dressing.

clean the area with normal saline solution and cover it with a protective dressing. Explanation: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

When teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include? burning or pain with urination complaints of a stiff neck fever disappearing for longer than 24 hours, then returning history of febrile seizures

complaints of a stiff neck Explanation: The nurse should discuss complaints of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, fever that disappears for 24 hours then returns, and a history of febrile seizures should be addressed by the physician but can wait until office hours.

Which abnormal blood value would not be improved by dialysis treatment? elevated serum creatinine level hyperkalemia decreased hemoglobin concentration hypernatremia

decreased hemoglobin concentration Explanation: Dialysis has no effect on hemoglobin levels because some red blood cells are injured during the procedure; dialysis aggravates a low hemoglobin concentration and may contribute to anemia. Dialysis will clear metabolic waste products from the body and correct electrolyte imbalances.

Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition? development of a future Rh-positive fetus an antibody response to Rh-negative blood a future pregnancy resulting in abortion development of Rh-positive antibodies

development of Rh-positive antibodies Explanation: Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative mothers do not develop sensitivities if the fetus is also Rh negative.

When assessing a child with bronchiolitis, which finding does the nurse expect? clubbed fingers barrel chest barking cough and stridor productive cough

productive cough Explanation: Bronchiolitis causes a productive cough. Clubbed fingers and a barrel chest are more likely in a client with chronic respiratory problems. A barking cough is associated with croup.

The nurse is preparing a treatment plan for a child with sickle cell anemia in vaso-occlusive crisis. What is the most important nursing intervention to include? Managing pain Providing a cool environment Immobilizing the affected part Restricting fluids

Managing pain Explanation: Pain management is an important aspect in the care of a client with sickle cell anemia in vaso-occlusive crisis. The goal is to prevent sickling. This can be accomplished by promoting tissue oxygenation, hydration, and rest, which minimizes energy expenditure and oxygen utilization. A cool environment can cause vasoconstriction, more sickling and pain. Immobilization can promote stasis and increase sickling.

For a child with hemophilia, what is the most important nursing goal? Enhancing tissue perfusion Preventing bleeding episodes Promoting tissue oxygenation Controlling pain

Preventing bleeding episodes Explanation: A child with hemophilia is prone to bleeding episodes stemming from coagulation problems. Therefore, the primary nursing goal is to prevent bleeding episodes and possible hemorrhage. A secondary effect of preventing bleeding episodes is maintenance of tissue perfusion and oxygenation. Hemophilia rarely causes pain.

The nurses discusses appropriate iron-rich food selections with the parent of an 11-month-old infant with iron deficiency anemia. The nurse determines that teaching has been successful when the parent verbalizes that she will include which foods in the child's diet? eggs, fortified cereals, meats, and green vegetables fruits, cereals, milk, and yellow vegetables eggs, fruits, milk, and mixed vegetables juices, fruits, fortified cereals, and milk

eggs, fortified cereals, meats, and green vegetables Explanation: Relatively high amounts of iron are contained in eggs, fortified cereals, meats, and green vegetables. Juices, fruits, yellow or mixed vegetables, and milk contain less iron and are not the best choices.

The best way for a nurse to assess pain in an 18-month-old client is to check the client's pupils. observe for behavioral changes. ask the client, "Are you feeling any pain?" tell the caregivers to call if the client has pain.

observe for behavioral changes. Explanation: Behavioral changes are common signs of pain and are especially valuable indicators in an 18-month-old client, who has limited verbal skills. Evaluating pupillary response isn't an appropriate technique for assessing pain. Requesting a caregiver report of a client's pain isn't a reliable assessment technique.

The nurse is offering nutritional instruction to the parents of a preschooler who has undergone a tonsillectomy and adenoidectomy. What food choice by the parents would indicate successful teaching? meat loaf and uncooked carrots pork and noodle casserole cream of chicken soup and orange sherbet hot dog and potato chips

cream of chicken soup and orange sherbet Explanation: For the first few days after a tonsillectomy and adenoidectomy, liquids and soft foods are best tolerated by the child while the throat is sore. Children typically do not chew their food thoroughly, and solid foods are to be avoided because they are difficult to swallow. Although meat loaf would be considered a soft food, uncooked carrots would not be. Pork is frequently difficult to chew. Foods that have sharp edges, such as potato chips, are contraindicated because they are hard to chew and may cause more throat discomfort.

The mother tells the nurse she will be afraid to allow her child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fitness is important for children with hemophilia, which activity should the nurse suggest as ideal? snow skiing swimming basketball gymnastics

swimming Explanation: Swimming is an ideal activity for a child with hemophilia because it is a noncontact sport. Many noncontact sports and physical activities that do not place excessive strain on joints are also appropriate. Such activities strengthen the muscles surrounding joints and help control bleeding in these areas. Noncontact sports also enhance general mental and physical well-being. Falls and subsequent injury to the child may occur with snow skiing. Basketball is a contact sport and therefore increases the child's risk for injury. Gymnastics is a very strenuous sport. Gymnasts frequently have muscle and joint injuries that result in bleeding episodes.

The nurse is providing teaching to the parents of a young child with a urinary tract infection. The nurse's goal is to help the parents understand their role in the treatment of the infection. Which statement by the parents lets the nurse know that the teaching has been successful? "We can treat the infection by increasing oral fluid intake." "We need to encourage cranberry juice to treat the infection." "We need to administer the oral antibiotics as prescribed." "We need to come to the emergency department for IV fluids."

"We need to administer the oral antibiotics as prescribed." Explanation: Oral administration of antibiotics specific to the pathogen is the best course of treatment for a child with a urinary tract infection. Increasing oral fluid or giving cranberry juice may be preventative measures to protect against getting a urinary infection, but they would not treat the infection. Going to the emergency department for IV fluids is not a recommended course of action.

The nurse is caring for a child with cystic fibrosis who is admitted to the floor with an upper respiratory tract infection. The child has labored breathing and a congested, nonproductive cough. What is the immediate priority for the nurse? infection airway nutrition family coping

airway Explanation: The nurse's first priority is to assess the child's respiratory status and to maintain patency of the airway. Infection is present but not a priority. Nutrition and family coping are issues for the child but not priorities.

A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: production of thick, sticky mucus. harsh, nonproductive cough. stridor. unilateral decrease in breath sounds.

production of thick, sticky mucus. Explanation: Cystic fibrosis is associated with the production of thick, sticky mucus. Cystic fibrosis isn't associated with harsh, nonproductive coughing or with stridor or unilateral decrease in breath sounds.

A nurse is reviewing an infant's progress notes. Progress notes 10/15/16 0800 Four-month-old infant admitted last evening. Weight: 4.95 kg. (10%) Height: 66 cm (95%), Frequent episodes of bradycardia, tachypnea. Breastfeeding every 4 hours for 30 minutes on each side. What notations would lead the nurse to suspect that this infant has a ventricular septal defect? Select all that apply. tachypnea plots at 95th percentile for height on growth chart plots at the 10th percentile for weight on growth chart bradycardia increased length of time to finish breastfeeding

tachypnea plots at the 10th percentile for weight on growth chart increased length of time to finish breastfeeding Explanation: Children with a ventricular septal defect usually present with symptoms of heart failure, poor growth and development, and failure to thrive. They also have difficulty feeding due to their decreased cardiac output and tachypnea.

The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which care is most appropriate? Fit the diaper under the straps. Leave the harness off while the infant sleeps. Check for skin redness under straps every other day. Put powder on the skin under the straps every day.

Fit the diaper under the straps. Explanation: The Pavlik harness is worn over a diaper. Knee socks are also worn to prevent the straps and foot and leg pieces from rubbing directly on the skin. For maximum results, the infant needs to wear the harness continuously. The skin should be inspected several times a day, not every other day, for signs of redness or irritation. Lotions and powders are to be avoided because they can cake and irritate the skin.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? applying ice to the foot massaging the toes elevating the foot of the bed placing the child on his right side

elevating the foot of the bed Explanation: To relieve edema of the toes, the most appropriate reaction is to raise the affected extremity above heart level such as by elevating the foot of the bed. Applying ice, massaging the toes, and placing the child on his right side wouldn't reduce swelling.

A nurse is teaching the parents of an infant with cystic fibrosis about chest percussion therapy. Which statement by the nurse is most accurate in explaining the rationale for using chest percussion on infants with cystic fibrosis? "Chest percussion is used as an adjunct to nebulizer treatments." "Chest percussion helps clear secretions out of the lungs." "Chest percussion is needed everyday to prevent infection." "Chest percussion is needed only when the child is ill."

"Chest percussion helps clear secretions out of the lungs." Explanation: The major effect of chest percussion is to vibrate the airways in the lungs. This helps move mucus from the smaller airways to the larger airways where mucus can be coughed up. It is generally performed twice daily, in the morning and at bedtime, but the number of times will be increased if the child has an infection or is experiencing difficulty breathing. It does not prevent infection, nor is it used as an adjunct to nebulizer treatments.

A 7-year-old has been diagnosed with bacterial meningitis. Who should receive chemoprophylaxis? all children at the school all household contacts and close contacts the entire community household contacts only

all household contacts and close contacts Explanation: Chemoprophylaxis should be given to household contacts and close contacts only. To prevent community outbreaks, chemoprophylaxis with rifampin 600 mg twice a day for 2 days or a single dose of ciprofloxacin 500 mg is indicated.

An adolescent with type 1 diabetes is monitoring her blood glucose level at home. Which action indicates that the client understands appropriate care management strategies for a blood glucose level of 250 mg/dL (13.9 mmol/L)? skipping the next dose of insulin taking insulin eating a high-carbohydrate meal injecting glucagon

taking insulin Explanation: A blood glucose level of 250 mg/dL (13.9 mmol/L) is indicative of hyperglycemia. The adolescent should take insulin to lower glucose levels, drink water to prevent dehydration, and contact the health care provider.Skipping a dose of insulin is inappropriate without first contacting the primary care provider. In this case, skipping a dose would worsen the adolescent's hyperglycemia.Hypoglycemic episodes are managed by ingesting foods or beverages with high-carbohydrate content.Glucagon is used if the adolescent has hypoglycemia and is unconscious.

When preparing the teaching plan for the mother of a child with asthma, what information should the nurse include as a sign to alert the mother that her child is having an asthma attack? secretion of thin, copious mucus tight, productive cough wheezing on expiration temperature of 99.4° F (37.4° C)

wheezing on expiration Explanation: The child who is experiencing an asthma attack typically demonstrates wheezing on expiration initially. This results from air moving through narrowed airways secondary to bronchoconstriction. The child's expiratory phase is normally longer than the inspiratory phase. Expiration is passive as the diaphragm relaxes. During an asthma attack, secretions are thick and are not usually expelled until the bronchioles are more relaxed. At the beginning of an asthma attack the cough will be tight but not productive. Fever is not always present unless there is an infection that may have triggered the attack.

A client with iron deficiency anemia was prescribed ferrous sulfate. Which statement by the caregiver would indicate a need for further instruction on proper administration? "I mix the medication in milk to make it taste better." "I give the medication in the morning before breakfast." "I give the ferrous sulfate at a different time than my child's other medications." "I encourage my child to drink lots of fluids."

"I mix the medication in milk to make it taste better." Explanation: Ferrous sulfate absorbs better with juices containing vitamin C. However, food containing calcium will decrease the medication's absorption. Ferrous sulfate should be given on an empty stomach if tolerated. Many medications alter the absorption of ferrous sulfate and should be administered at least 1-2 hours apart. Drinking lots of fluid will help with constipation, a common side effect of ferrous sulfate.

The nurse is teaching a parent and child with iron deficiency anemia. The parent asks the nurse why the ferrous sulfate needs to be mixed with citrus juice. What is the best response by the nurse? "The vitamin C in the citrus juice helps with iron absorption." "Having food and juice in the stomach helps with iron absorption." "The citrus juice counteracts the unpleasant taste of the iron." "The child will take the iron mixed with juice better than water."

"The vitamin C in the citrus juice helps with iron absorption." Explanation: Administering an oral iron supplement with citrus juice or another vitamin C source enhances its absorption. If possible, doses should be administered between meals because gastric acidity and absence of food promote iron absorption. Although citrus juice may improve the taste of an oral iron supplement, this isn't the primary reason for mixing the two together. Telling the parent that juice is better than water is not answering the question about the reason to use a citrus juice.

During a well-baby visit, a 2-month-old infant receives a diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How does the nurse respond? "This vaccine prevents infection by the poliovirus." "This vaccine protects against serious bacterial infections, such as meningitis." "This vaccine prevents infection by the hepatitis B virus, which can cause liver damage." "This vaccine prevents susceptible children from getting chickenpox or smallpox."

"This vaccine protects against serious bacterial infections, such as meningitis." Explanation: The Hib vaccine provides protection against serious childhood infections caused by H. influenzae type b virus, such as meningitis and bacterial pneumonia. The Hib vaccine doesn't prevent infection by the influenza virus, hepatitis B virus, or the varicella virus (chickenpox). The influenza virus vaccine provides immunity to various strains of the influenza virus. The Heptavax-B vaccine prevents infection by the hepatitis B virus. The varicella vaccine prevents the chickenpox.

A nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action should the nurse take? Tell the parents they should be glad their child has lived this long. Encourage the parents to continue to do as much for their child as they can so that the child is not responsible for his or her own care. Counsel the parents on not having any more children because all future children will also have cystic fibrosis. Encourage the parents to get connected with support groups such as the Cystic Fibrosis Foundation.

Encourage the parents to get connected with support groups such as the Cystic Fibrosis Foundation. Explanation: The nurse should encourage the parents to treat their child as much like a normal child as possible. The nurse should avoid being critical of how parents handle their child's condition. Children with cystic fibrosis can live productive lives well into adulthood, so telling the parents they're lucky their child has lived this long is not only rude, but also inappropriate. Although each child the couple has a 25% chance of having cystic fibrosis, it isn't appropriate for the nurse to counsel the parents. If they express uncertainty about having more children, the nurse should refer them to their physician or a genetic counselor. The best answer to encourage the parents to get help from support groups so they are better able to copy with their own feelings.

A toddler with croup is given a racemic epinephrine treatment because of increasing respiratory distress. Which finding indicates that the treatment has been effective? Color is normal. Retractions are less severe. Heart rate is 100 bpm. Pulse oximeter reads 90.

Retractions are less severe. Explanation: Epinephrine in an inhalant form can be given to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening.Children with croup may not manifest with color change. A heart rate of 100 is normal for a toddler and tells the nurse very little about a child's degree of respiratory distress. While no data is given to show that the pulse oximeter reading was improving, a oxygen saturation of less than 92% in room air reflects suboptimal oxygenation.

A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first? a crying 4-year-old child with a laceration on the scalp a 3-year-old child with a barking cough and flushed appearance a 3-year-old child with Down syndrome who's pale and asleep a 2-year-old child with stridorous breath sounds, sitting up and drooling

a 2-year-old child with stridorous breath sounds, sitting up and drooling Explanation: The child with the airway emergency should be treated first because of the risk of epiglottitis. The 3-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather information about the child with Down syndrome to determine the priority of care.

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16,000 X 109/L). What is priority for nursing intervention? infection airway obstruction difficulty breathing potential for aspiration

airway obstruction Explanation: The child's signs and symptoms in conjunction with the acute onset suggest possible croup or epiglottitis. The priority diagnosis at this time is airway obstruction. The airway may become completely occluded by the epiglottis at any time. Although the child has an infection, and the client has respiratory distress, the immediate priority is to establish and maintain a patent airway. No evidence is provided to support the potential for aspiration.

A 4-year-old child is seen at the clinic for a mild iron deficiency anemia caused by a poor diet. The parents ask the nurse what type of treatment to expect. What is the most appropriate response by the nurse? iron replacement and change of diet transfusion of packed red blood cells preparation for bone marrow transplant splenectomy and steroid therapy

iron replacement and change of diet Explanation: Because the main etiological factor is diet, treatment would focus on addressing the iron deficiency in the diet, rather than more drastic options such as blood transfusion, bone marrow transplant, splenectomy, and steroid therapy.

The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which signs and symptoms? Select all that apply. irritability headache mood swings bulging fontanel emesis

irritability bulging fontanel emesis Explanation: Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.

Which signs and symptoms would lead the nurse to suspect a child has tetralogy of Fallot (TOF)? Select all that apply. murmur history of squatting bounding pulse cyanosis faint pulse tachypnea

murmur history of squatting cyanosis tachypnea Explanation: TOF is a heart condition with four defects: pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. A systolic murmur, cyanosis, and tachypnea are all symptoms of TOF. Toddlers with uncorrected defects instinctively squat (knee-chest position) to decrease the return of systemic venous blood to the heart. Coaractation of the aorta is a narrowing in the descending aorta, obstructing the systemic blood outflow. Infants with severe constriction may present with faint pulse in lower extremities and bounding upper extremities pulses.

A nurse is caring for an infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent? Obtain consent from the foster parents. Call Child Protective Services. Contact the child's biological parent. Contact the unit's director of nursing.

Obtain consent from the foster parents. Explanation: Foster parents have the right to consent to medical care of minors in their care. The parents of a minor in foster care don't have authority to make decisions regarding the child's care. The nurse should call Child Protective Services only if she has concerns about a foster parent's authenticity. The nurse needn't notify the director of nursing unless complications occur.

The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate? symmetrical thigh and gluteal folds Ortolani's sign increased hip abduction femoral lengthening

Ortolani's sign Explanation: Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

The nurse is caring for a 7-year-old child with diurnal enuresis. When discussing home treatment of this problem with the parents, what is the best advice for the nurse to give? Follow a schedule for the child to urinate. Restrict gas-producing foods. Restrict the child's activity when enuresis occurs. Continue to have the child wear a diaper.

Follow a schedule for the child to urinate. Explanation: Following a schedule helps to ensure complete emptying of the bladder at regular intervals. Gas-producing foods have no relationship to enuresis. Restricting the activity of a 7-year-old child is likely to be ineffective, and forcing the child to wear a diaper is not age-appropriate.

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip (DDH)? Select all that apply. negative Ortolani test positive Barlow test asymmetrical leg skin folds limitation in adduction of the affected leg lengthening of the affected leg

positive Barlow test asymmetrical leg skin folds Explanation: Developmental dysplasia (dislocation) of the hip is an abnormal formation of the hip joint in which the ball on the top of the femur is not held firmly in the socket. A neonate with DDH will have a positive Ortolani test, a positive Barlow test, and asymmetrical skin folds in the thigh. The affected leg has limited abduction and appears shorter than the unaffected leg in a neonate with DDH.

The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. What information should the nurse give to the clients? 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.

A client has just received a dose of theophylline I.V. for asthma. What assessment finding should the nurse expect? Increased coughing because of postnasal drip decreased pulmonary wheezing stridor white blood cell count of 12,000/?l

decreased pulmonary wheezing Explanation: Methylxanthines such as theophylline are highly potent bronchodilators used to relieve asthma symptoms. The bronchodilation will result in decreased wheezing. None of the other options are seen after administration of theophylline.

A child is admitted to the emergency department with an acute asthma attack. Which early assessment finding does the nurse expect? decreased respiratory rate expiratory wheezing inspiratory stridor cyanosis

expiratory wheezing Explanation: Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma causes an increased respiratory rate. Inspiratory stridor more commonly accompanies croup. Cyanosis would be a sign of severe hypoxia and would be a late sign.

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone? autonomy initiative industry identity

identity Explanation: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

The nurse is caring for a child hospitalized with epiglottitis. What will the nurse assign as the highest priority nursing diagnosis? ineffective airway clearance related to swelling of the epiglottis anxiety related to difficulty breathing deficient fluid volume related to difficulty swallowing fear related to change in environment

ineffective airway clearance related to swelling of the epiglottis Explanation: Because airway obstruction is a life-threatening complication of epiglottitis, ineffective airway clearance takes highest priority. Fear, deficient fluid volume, and anxiety are important but don't take precedence over ineffective airway clearance and ensuring airway patency.

The nurse is assessing a child with type 1 diabetes mellitus who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child? Make a referral to the pediatric diabetes nurse. Prepare to administer intravenous fluids and insulin per order. Teach the family about the prevention of this complication of diabetes. Monitor the child closely in the emergency department before transfer to the medical unit.

Prepare to administer intravenous fluids and insulin per order. Explanation: Diabetic ketoacidosis, the most complete state of insulin deficiency, is a life-threatening condition. The child should be admitted to an intensive care unit for management. Treatment would consist of rapid assessment, adequate insulin to reduce the elevated blood glucose level, fluids to overcome dehydration, and electrolyte replacement. Education would be a priority after the child has stabilized.

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 teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? Encourage a high-calorie, high-protein diet. Restrict fluids to 1,500 ml per day. Limit salt intake to 2 g per day. Encourage foods high in vitamin B.

Encourage a high-calorie, high-protein diet. Explanation: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

The nurse assesses a child with fever, sensitivity to light, and a red rash on the back. How will the nurse assess for Kernig's sign? Have the child lie supine with flexed knees, then ask the child to extend the knees. Have the child sit, and tap the child's face over the facial nerve area. Place the child in the supine position, and inflate a blood pressure cuff on the arm. Have the child stand, and ask the child to flex the neck by bringing the chin to the chest.

Have the child lie supine with flexed knees, then ask the child to extend the knees. Explanation: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign: place the client is in the supine position with knees flexed; ask the child to flex a leg at the hip so that the thigh is brought to a position perpendicular to the trunk; then ask the child to extend the knee. If meningeal irritation is present, the knee can't be extended, and attempts to extend the knee result in pain. Chvostek's sign and Trousseau's sign are indicators of calcium deficit. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. Trousseau's sign is elicited by inflating a blood pressure cuff on the arm and observing the reaction of the metacarpal phalangeal joints, interphalangeal joints, and thumb. Brudzinski's sign is used to test for nuchal rigidity by flexing the client's neck and observing for leg and knee flexion.

A two-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the nurse's most important intervention? administer I.V. antibiotics provide oxygen by face mask establish and maintain the airway ask the parent to go to the waiting room

establish and maintain the airway Explanation: The initial priority is to establish and maintain the airway. Edema and an accumulation of secretions may contribute to airway obstruction. Antibiotics are not indicated for viral illnesses. Oxygen should be administered as soon as possible to decrease the child's distress. Allowing the child to stay with the parent reduces anxiety and distress.

Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the health care provider (HCP) based on the interpretation that these findings may lead to which condition? respiratory arrest bronchial pneumonia intraventricular hemorrhage epiglottitis

respiratory arrest Explanation: Periods of apnea lasting longer than 20 seconds, mild cyanosis, and a heart rate of <100 bpm (bradycardia) are associated with a potentially life-threatening event and subsequent respiratory arrest. The neonate needs further evaluation by the HCP . Pneumonia is associated with tachycardia, anorexia, malaise, cyanosis, diminished breath sounds, and crackles. Intraventricular hemorrhage is associated with prematurity. Assessment findings include bulging fontanels and seizures. Epiglottitis is a bacterial form of croup. Assessment findings include inspiratory stridor, cough, and irritability. It occurs most commonly in children age 3 to 7 years.

A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which interventions are indicated? Select all that apply. Restrain the child. Have the parent read to the child. Administer a sedative. Encourage the parent to hold the child. Tell the child the mask will help him breathe better. Ask the parent to leave the child's bedside.

Have the parent read to the child. Encourage the parent to hold the child. Explanation: Children in respiratory distress need to be kept as quiet as possible to decrease respiratory and heart rates. Toddlers need a parent with them for security. The best way to quiet toddlers is to read to or hold them. Restraints increase heart and respiratory rates. A sedative will mask the signs of further respiratory distress. Although you could tell toddlers that a mask will help with breathing, they cannot understand the rationale and thus fully comprehend its importance. Asking the parents to leave the bedside will most likely result in greater upset, further contributing to respiratory distress.

A mother asks the nurse how to handle her 4-year-old child, who recently has had episodes of urinary incontinence after being completely toilet-trained. What is the best response by the nurse? "What have you done to prevent this from happening?" "Have your other children experienced this same thing?" "Has your child experienced any recent changes in routine?" "Is your child angry with you about something?"

"Has your child experienced any recent changes in routine?" Explanation: The nurse recognizes that changes in routine may cause the child to regress to earlier stages of development. A child's skills remain intact, although increased stress may prevent the child from using these skills. Therefore it is important to identify the cause for the regressive behavior. Regressive behavior is common in response to fear of the unknown, not as a result of being angry with parents. Regressive behavior is individual and not dependent on sibling behavior. Asking the parent what has been done to prevent the behavior places blame on the parent and is not appropriate at this time.

A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request? Assess the child's pain by asking the child to rate the pain on a 1 to 10 scale. Prepare to administer the ordered pain medication. Use the Faces Pain Scale to assess the child's degree of pain. Document the report of pain, and note the time of the last pain medication.

Use the Faces Pain Scale to assess the child's degree of pain. Explanation: The nurse should assess the client's pain level using the age-appropriate Faces Pain Scale. After the pain assessment, the nurse should determine the time previous pain medications were administered and medicate accordingly.

A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen? acute, painful musculoskeletal conditions skeletal muscle hyperactivity secondary to cerebral palsy spasticity related to stroke muscle spasms with paraplegia or quadriplegia from spinal cord lesions

muscle spasms with paraplegia or quadriplegia from spinal cord lesions Explanation: Baclofen's principal clinical indication is for the paraplegic or quadriplegic client with spinal cord lesions, most commonly caused by multiple sclerosis or trauma. For these clients, baclofen significantly reduces the number and severity of painful flexor spasms. Baclofen isn't indicated for acute, painful musculoskeletal conditions; skeletal muscle hyperactivity secondary to cerebral palsy; or spasticity related to stroke.

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.

A nurse is caring for a toddler in respiratory distress requiring endotracheal intubation. When gathering supplies, which item should the nurse obtain that is most important for this child? uncuffed endotracheal tube curved blade laryngoscope pain medication nasogastric tube

uncuffed endotracheal tube Explanation: An uncuffed endotracheal tube is used because the cricoid cartilage in the toddler is the narrowest part of the larynx and provides a natural seal. This aspect keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. Although the trachea is shorter and the larynx is anterior and cephalad, these aren't reasons to choose an uncuffed tube. A straight blade is used on the laryngoscope to intubate an infant and young children. Curved blades are used in older children (usually 8 years or older). A child needing intubation would require a sedative medication and/or a paralytic medication. A nasogastric tube will be inserted but generally not until intubation is complete.

After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following? "As my child grows, she may have increased fatigue and difficulty breathing." "My child may need to have antibiotics if she develops an infection." "This condition occurs more commonly in females than in males." "About half of the children born with this defect heal spontaneously."

"About half of the children born with this defect heal spontaneously." Explanation: A child with atrial septal defect will be monitored by a cardiologist. Nonsurgical closure may be attempted via cardiac catheterization. Surgical closure, using either a prosthetic patch or sutures, is performed on an elective basis early in childhood. Children diagnosed with this disorder do not have spontaneous healing or closure. About 20% to 60% of children born with a ventricular septal defect, an abnormal opening between the right and left ventricles, have spontaneous closure. Atrial septal defect accounts for approximately 10% of all congenital heart disease and is seen in more female than male neonates. This lesion consists of an abnormal opening between the atria. Ostium secundum, a defect located in the middle of the atrial septum, is the most common type seen. As the child grows, she may experience fatigue and dyspnea on exertion. A large defect may result in congestive heart failure if the lesion is unrepaired. Bacterial endocarditis prophylaxis with antibiotics may be ordered if the child develops an infection.

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal? decreases pain at the surgical site keeps the new urethra from closing measures his urine correctly prevents bladder spasms

keeps the new urethra from closing Explanation: The main purpose of the urethral catheter is to maintain patency of the reconstructed urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The urethral catheter will have no effect on the child's pain level. In fact, because bladder spasms are associated with its use, the child's problems of pain may actually increase. Urine output can be measured through the suprapubic catheter because it provides an alternative route for urinary elimination, thus keeping the bladder empty and pressure-free.

The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which finding? Ortolani's "click" limited abduction Galeazzi's sign asymmetric gluteal folds

asymmetric gluteal folds Explanation: This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani "click" occurs when the nurse feels the femur sliding into the acetabulum with a "click." Limited abduction may be observed during an attempt to abduct the infant's thighs. Galeazzi's sign reveals femoral foreshortening and is observed by flexing the thighs.

A parent brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. Limit fluids for the next few days to decrease the frequency of urination. Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Provide instructions only to the parent, not the child. Tell the parent to have the child wipe the back to the front after voiding and defecation.

Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Explanation: Assessing the parent's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be taken to eradicate the organism and prevent recurrence, even if the child's signs and symptoms decrease. Fluids should be encouraged, not limited, to prevent urinary stasis and help flush the organism from the urinary tract. Instructions should be given at the child's level of comprehension to help the child better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.

When examining school-age and adolescent clients, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening? Have the client stand firmly on both feet and bend forward at the hips, with the trunk exposed. Listen for a clicking sound as the client abducts the hips. Have the client run the heel of one foot down the shin of the other leg while standing. Have the client shrug the shoulders as the nurse applies mild pressure to the shoulders.

Have the client stand firmly on both feet and bend forward at the hips, with the trunk exposed. Explanation: To screen for scoliosis, a lateral curvature of the spine, the nurse has the client stand firmly on both feet with the trunk exposed and examines the client from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the client to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. Listening for a clicking sound while the client abducts the hips is appropriate when screening for congenital hip dysplasia. The heel-to-shin test evaluates cerebellar function and having the client shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve XI.

A nurse is giving instructions to parents of a school-age child diagnosed with sickle cell anemia. The instructions should include: applying cold to affected areas to reduce the child's discomfort. restricting the child's fluids during crisis situations. avoiding areas of low oxygen availability such as high altitudes. encouraging the child to exercise to reduce the likelihood of crisis.

avoiding areas of low oxygen availability such as high altitudes. Explanation: The child should avoid areas of low oxygen, such as high altitudes, because they may precipitate sickle cell crisis. Applying warm compresses will reduce discomfort to the affected area; cold compresses, however, may add to discomfort by increasing sickling and impairing circulation. The child should be encouraged to drink fluids to rehydrate cells. Strenuous exercise may induce, not reduce, sickle cell crisis.

A 15-month-old has just received routine immunizations, including DTaP, IPV, and MMR. What information would the nurse give to the parents before they leave the office? Select all that apply. Minor symptoms can be treated with acetaminophen. Analgesics for discomfort are suggested following arrival home. Call the office if the toddler develops a temperature above 103°F (39.4°C), seizures, or difficulty breathing. Discomfort at the immunization site and mild fever are common. The immunizations prevent the toddler from contracting associated diseases. The toddler should restrict activity for the remainder of the day.

Minor symptoms can be treated with acetaminophen. Call the office if the toddler develops a temperature above 103°F (39.4°C), seizures, or difficulty breathing. Discomfort at the immunization site and mild fever are common. Explanation: Minor symptoms, such as soreness at the immunization site and mild fever, can be treated with acetaminophen or ibuprofen. While some infants may experience discomfort, not all do; thus, analgesics are only given per healthcare provider guidelines and not routinely suggested to all. The parents would notify the clinic if serious complications (such as a fever above 103°F [39.4°C], seizures, or difficulty breathing) occur. Minor discomforts, such as soreness and mild fever, are common after immunizations. Immunizing the child decreases the health risks associated with contracting certain diseases; it does not prevent the toddler from acquiring them. Although the child may prefer to rest after immunizations, it is not necessary to restrict activity.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family? Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. Tube feedings are less invasive than total parenteral nutrition; either one can meet hydration and nutritional needs. Demonstrate to the family that pureed foods or liquids result in coughing. This signifies the importance of the need for a feeding tube. Because of limited mobility, the client is susceptible to developing pneumonia. Extra nutrients are necessary to strengthen the immune system and promote recovery.

Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. Explanation: A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube.

A school-age client with diabetes is placed on an intermediate-acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do? Help her regain lost weight. Provide carbohydrates for immediate use. Prevent late night hypoglycemia. Help her stay on her diet.

Prevent late night hypoglycemia. Explanation: Intermediate acting insulins peaks in 6 to 8 hours, which would occur during sleep. A bedtime snack is needed to prevent late night hypoglycemia. The snack is not given to help regain weight. Milk contains fat and protein, which cause delayed absorption into the blood stream and also maintains the blood glucose level at night when the intermediate acting insulin will peak. The snack is not used to provide carbohydrates for immediate use because an intermediate acting insulin, unlike regular insulin, does not peak immediately. The snack has nothing to do with a diet.

A student nurse working with a registered nurse is assessing a child with epiglottitis. The student nurse tells the child that she must look into his/her throat. Which intervention by the registered nurse is most appropriate? Assist the child into a supine position for visualization of the throat. Give the student nurse a sterile tongue blade and culture swab. Tell the student nurse that the registered nurse will visually examine the child's throat. Tell the student nurse that the anesthesiologist will visually examine the child's throat.

Tell the student nurse that the anesthesiologist will visually examine the child's throat. Explanation: Direct visualization of the epiglottis can trigger reflex laryngospasm and cause complete airway obstruction. Only an anesthetist or a physician skilled in pediatric intubation may perform this procedure. Placing the child in a supine position may cause an airway obstruction.

A child with cystic fibrosis does not like taking a pancreatic enzyme supplement with meals and snacks. The parent does not like to force the child to take the supplement. What is the most important reason for the child to take the pancreatic enzyme supplement with meals and snacks? The child will become dehydrated if the supplement is not taken with meals and snacks. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear. The child will experience severe diarrhea if the supplement is not taken as prescribed.

The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins. Explanation: The child must take the pancreatic enzyme supplement with meals and snacks to help absorb nutrients so he can grow and develop normally. In cystic fibrosis, the normally liquid mucus is tenacious and blocks three digestive enzymes from entering the duodenum and digesting essential nutrients. Without the supplemental pancreatic enzyme, the child will have voluminous, foul, fatty stools due to the undigested nutrients and may experience developmental delays due to malnutrition. Dehydration is not a problem related to cystic fibrosis. The pancreatic enzymes have no effect on the viscosity of the tenacious mucus. Diarrhea is not caused by failing to take the pancreatic enzyme supplement.

A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices that the toddler limps when walking. Which would be appropriate to use when assessing this toddler for developmental dysplasia of the hip? Ortolani's maneuver Barlow's maneuver Adam's position Trendelenburg's sign

Trendelenburg's sign Explanation: A Trendelenburg's sign is seen in children with developmental dysplasia of the hip who are walking. Weight bearing causes the pelvis to tilt downward on the unaffected side instead of upward as it would normally. Ortolani's maneuver is used during the neonatal period to assess developmental dysplasia of the hip in infants. With the infant quiet, relaxed, and lying on the back, the hips and knees are flexed at right angles. The knees are moved to abduction and pressure is exerted. If the femoral head moves forward, then it is dislocated. Barlow's maneuver is used to assess developmental dysplasia of the hip in infants. As the femur is moved into or out of the acetabulum, a "clunk" is heard, indicating dislocation. Adam's position is used to evaluate for structural scoliosis. The child bends forward with feet together and arms hanging freely or with palms together.

A nurse manager is reviewing charts of several toddlers on a pediatric unit. The manager notices that the weight of the toddlers has not been documented and decides to address the issue with the staff. Which is the most critical information for the nurse manager to share with the staff regarding this situation? Undocumented weights could result in medication errors. Weights are necessary to plan pediatric meals accurately. Failing to chart weights will lead to a work suspension. Documenting weights helps parents see a child's progress.

Undocumented weights could result in medication errors. Explanation: A child whose weight has not been documented is at great risk for a medication error because many medication dosages are related to the child's weight. Although the other options may be shared by the nurse manager, they are not as critical to the safety of the child.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling a 3-year-old with a fever of 100° F (37.8° C), a barky cough, and mild intercostal retractions a 4-year-old with a fever of 101° F (38.3° C), a hoarse cough, inspiratory stridor, and restlessness a 13-year-old with a fever of 104° F (40° C), chills, and a cough with thick yellow secretions

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling Explanation: This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.

A 2-year-old client is brought to the emergency department with suspected croup. The client appears frightened and cries as the nurse approaches him. The nurse needs to assess the client's breath sounds. The best way to approach the client is to expose the client's chest quickly and auscultate breath sounds as quickly and efficiently as possible. ask the caregiver to wait briefly outside until the assessment is over. tell the client the nurse is going to listen to the chest with the stethoscope. allow the client to handle the stethoscope before the nurse listens to the client's lungs.

allow the client to handle the stethoscope before the nurse listens to the client's lungs. Explanation: The best way to approach the client is to allow the client to handle the stethoscope because toddlers are naturally curious about their environment. Letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should only expose one area at a time during assessment and should approach the client slowly and unhurriedly. The caregiver should be encouraged to hold and console the client and to comfort the client with objects with which the client is familiar, and the client should be given limited choices to allow autonomy such as, "Do you want me to listen first to the front of your chest or your back?"

Which factor, if described by the parents of a child with cystic fibrosis (CF), indicates that the parents understand the underlying problem of the disease? an abnormality in the body's mucus-secreting glands formation of fibrous cysts in various body organs failure of the pancreatic ducts to develop properly reaction to the formation of antibodies against streptococcus

an abnormality in the body's mucus-secreting glands Explanation: CF is characterized by a dysfunction in the body's mucus-producing exocrine glands. The mucus secretions are thick and sticky rather than thin and slippery. The mucus obstructs the bronchi, bronchioles, and pancreatic ducts. Mucus plugs in the pancreatic ducts can prevent pancreatic digestive enzymes from reaching the small intestine, resulting in poor digestion and poor absorption of various food nutrients. Fibrous cysts do not form in various organs. Cystic fibrosis is an autosomal recessive inherited disorder and does not involve any reaction to the formation of antibodies against streptococcus.

A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse assesses the child and finds a hoarse voice, inspiratory stridor, fever, and a barking cough. What would the nurse anticipate for admission orders? cool mist humidification expectorant cough syrup antibiotics inhaled bronchodilator

cool mist humidification Explanation: Croup is a viral infection of the larynx and trachea associated with signs of a respiratory infection, such as a runny nose or cough. It is also a very common ailment of childhood. Because it is a virus, antibiotics are ineffective. Usually the first indication of croup is a cough that sounds like the bark of a dog or seal. The child may have trouble breathing because the tissue around the larynx is inflamed, constricting the trachea, and because the bronchial passages are blocked with mucus. The sound of air being forced through the narrowed airways may produce a hollow, raspy noise, called stridor, with each inhaled breath. Treatment includes cool mist humidification, acetaminophen for fever, and fluids. Bronchodilators work only on the bronchus and are not used for upper airways. What would most likely be administered is racemic epinephrine via nebulization. Cough syrups work on the lower airways, not the upper.

An adolescent with well-controlled type 1 diabetes has assumed complete management of the disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct the client to adjust the therapeutic regimen by: eating a snack before each gymnastics practice. measuring urine glucose level before each gymnastics practice. measuring blood glucose level after each gymnastics practice. increasing morning dosage of intermediate-acting insulin.

eating a snack before each gymnastics practice. Explanation: Because exercise decreases the blood glucose level, the nurse should instruct the client to eat a snack before engaging in physical activity to prevent a hypoglycemic episode. Measuring urine glucose level before each gymnastics practice is incorrect because the urine glucose level doesn't reflect the current blood glucose level. To prevent hypoglycemia, the blood glucose level should be measured before the activity, not after the activity. Increasing the morning dosage of intermediate-acting insulin may lead to hypoglycemia during gymnastics practice; to avoid this condition, the adolescent may need to decrease, not increase, the morning dosage of intermediate-acting insulin.

The nurse reviews with the parents how to care for their child with sickle cell anemia at home. The nurse determines that the parents understand the basic principles of home care when they state that they will implement which intervention? keeping the child with them at all times restricting the child's fluids at night encouraging their child to drink as much liquid as possible not allowing their child to play with other children

encouraging their child to drink as much liquid as possible Explanation: Because sickle cells tend to "log jam" in capillaries, it is important that the child receive adequate fluids day and night. The fluids increase blood volume and help prevent the log jam action that occurs during a crisis.The parents need to allow the child some independence for normal development. Keeping the child with them at all times is overprotective and will lead to dependency.Children with a chronic illness need to be around other children for normal growth and development. However, this child should not be around anyone with an active infection.

An emergency department nurse is caring for a child diagnosed with moderately severe croup. The nebulizer treatment of choice for a child with moderate to severe croup is: albuterol. budesonide. epinephrine. ipratropium bromide.

epinephrine. Explanation: Nebulized epinephrine is an adrenergic that reduces inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta2-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma. Budesonide is a corticosteroid inhaler that is recommended for children with mild to moderate croup. However, in moderate to severe croup, it is preferred that the corticosteroid is given orally.

A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. bulging anterior fontanel fever nuchal rigidity petechiae irritability photophobia

fever nuchal rigidity irritability photophobia Explanation: Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis.

A 4-year-old child with hydrocephalus is scheduled to have a ventriculoperitoneal shunt in the right side of the head. When developing the child's postoperative plan of care, the nurse should place the preschooler off of the operative site with the head of the bed in which position immediately after surgery? high Fowler's semi-Fowler's flat Trendelenburg

flat Explanation: For at least the first 24 hours after insertion of a ventriculoperitoneal shunt, the child is positioned off of the operative site with the head of the bed flat to prevent too rapid a decrease in cerebrospinal fluid pressure. Although elevating the head in Fowler's or semi-Fowler's position increases cerebrospinal fluid drainage and reduces intracranial pressure, a rapid reduction in the size of the ventricles can cause subdural hematoma. Elevating the foot of the bed in Trendelenburg position could increase intracranial pressure.

A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? obtain a throat culture place the child in a side-lying position have emergency airway equipment readily available obtain blood cultures

have emergency airway equipment readily available Explanation: With acute epiglottitis, the glottal structures become edematous. Emergency airway equipment and humidified oxygen should be readily available. The nurse should not attempt to visualize the epiglottis, use tongue blades or throat culture swabs, which can cause the epiglottis to spasm, and totally occlude the airway. Throat inspection should only be attempted when immediate intubation or tracheostomy can be performed in the event of further or complete obstruction. The child should always remain in a position that provides the most comfort, security, and ease of breathing. The child will often assumes a classic tripod posture with the trunk leaning forward, neck hyperextended, and chin thrust forward.

A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? knee-to-chest Fowler's Trendelenburg's prone

knee-to-chest Explanation: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.

The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which signs? decreased cardiac output with faint peripheral pulses profound cyanosis over most of the body loud cardiac murmurs through systole and diastole harsh systolic murmurs with a palpable thrill

loud cardiac murmurs through systole and diastole Explanation: With a patent ductus arteriosus, a cardiac defect marked by a failure of the patent ductus arteriosus to close completely at birth, blood from the aorta flows into the pulmonary arteries to be reoxygenated in the lungs and returned to the left atrium and ventricle. The effect of this altered circulation includes increased workload on the left side of the heart and increased pulmonary vascular congestion. Term infants are commonly asymptomatic, but a loud, machinery-like murmur may be heard throughout systole and diastole. This murmur may be accompanied by a suprasternal thrill, and the heart may be enlarged. Decreased cardiac output with faint peripheral pulses, poor peripheral perfusion, feeding difficulties, and severe congestive heart failure are symptoms associated with severe aortic stenosis. With this defect, the aortic valve is thickened and rigid, leading to decreased cardiac output and reduced myocardial blood flow. Profound cyanosis over most of the body, fatigue on exertion, feeding difficulties, and chronic hypoxemia are associated with tetralogy of Fallot. With this defect, malalignment of the ventricular system results in nonrestricted ventral septal defects, pulmonic stenosis, overriding of the aorta, and hypertrophy of the left ventricle. The heart appears boot shaped. A harsh systolic murmur with a palpable thrill is associated with truncus arteriosus. It is marked by incomplete division of the great vessel. This is caused by a ventral septal defect. Bounding pulses and a widening pulse pressure may also be present.

The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which factor? chronic anemia peripheral hypoxia delayed physical growth destruction of bone marrow

peripheral hypoxia Explanation: Clubbing of the fingers is one common finding in the child with persistent hypoxia, which leads to tissue changes in the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as the body attempts to improve the blood supply. Clubbing of the fingers is associated with polycythemia, not anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues. The child may be small for the chronological age, but clubbing does not result from slow physical growth. Destruction of the bone marrow is not related to this congenital heart malformation. Instead, bone marrow is actively producing erythrocytes to compensate for the chronic hypoxia.