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A nurse has given instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client states to:
Kegel exercises strengthen the perineal floor and are useful to prevent and manage cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds. Because the muscles that control urination also are involved in defecation, these exercises also can be done once during defecation. Otherwise, they may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes three or four times a day. Option 1 is not a correct method for performing Kegel exercises. Residual urine should not be held in the bladder for lengthy periods because it could promote urinary tract infection.
A nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which of the following is a characteristic of this type of nursing model practice?
Nursing personnel are led by an RN leader in providing care to a group of clients Rationale: In team nursing, nursing personnel are led by an RN leader to provide care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies primary nursing. Option 3 identifies a component of case management.
A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How will the nurse be most therapeutic in this situation?
Provide support to the mother regardless of her reaction to the newborn.
A nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to figure.
RLQ Rationale: When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are always present here normally.
A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which of the following will be prescribed initially?
Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be measured accurately on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed and treated after assessment, but this would not be the initial action. Intravenous fluids are administered at a rate sufficient to keep the child's urine output at 1 mL/kg of body weight per hour, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Child Health: Integumentary/AIDS/Infectious Diseases
A nurse is reviewing the record of a newborn infant and notes that the health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which of the following on data collection of the infant?
Rationale: A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely the result of ruptured blood vessels from head trauma during birth. It develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 identifies a caput succedaneum. Option 3 may indicate increased intracranial pressure. Option 4 may be associated with premature closure or craniosynostosis and should be investigated further.
A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which of the following medications?
Rationale: A complication of closed head injury is diabetes insipidus (DI). This may occur if the injury affects the hypothalamus, antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L/day generally requires treatment with DDAVP, an antidiuretic. Ethacrynic acid and mannitol are both diuretics, which would be contraindicated for this client. Dexamethasone is a glucocorticoid that is used to treat cerebral edema. This medication already may be prescribed for the head-injured client but does not relate to DI.
A nurse is reinforcing discharge instructions to the mother of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which of the following statements, if made by the mother of the child, indicates that further teaching is necessary?
Rationale: All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally 2-year-old children will want to be very active. Therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the child's temperature, provide analgesics, as needed, and monitor the urine output.
A nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. The nurse understands that which of the following is unassociated with this disorder?
Rationale: During the newborn assessment, imperforate anus should be easily identified visually. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. The presence of stool in the urine or vagina should be reported immediately as an indication of abnormal anorectal development. Currant jelly-like stool is not a clinical manifestation of this disorder.
A nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client?
Rationale: Electrolyte solutions such as lactated Ringer's are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement; 5% dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client takes nothing per mouth (NPO).
Which of the following would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?
Rationale: Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.
A nurse is providing instructions to a client taking ethambutol (Myambutol) about the medication. The nurse instructs the client to contact the health care provider immediately if which of the following occurs?
Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a safety hazard when driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin).
A nurse is reviewing the laboratory results of a client who has been diagnosed with multiple myeloma. Which of the following would the nurse expect to specifically note with this diagnosis?
Rationale: Findings that are indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia as a result of the release of calcium from the deteriorating bone tissue, and an elevated BUN level. An increased white blood cell count may or may not be present, but this is not specifically related to multiple myeloma.
A nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which of the following actions?
Rationale: If a nurse feels that the assignment is more difficult than the assignment delegated to other nurses on the unit, the nurse should discuss the assignment with the nurse manager of the neurological unit. The nurse may or may not have a more difficult assignment than the other nursing staff. However, this action will assist in either identifying the rationale for the assignment or determining if the assignment is actually more difficult. A nurse should not refuse an assignment. Specific situations may be present in which a nurse should not take care of a specific client. An example of this type of situation may be if a pregnant nurse is assigned to care for a client with rubella or a client with an internal radiation implant. In these situations, the nurse also should discuss the assignment with the nurse manager. The nurse should not return to the cardiac unit. This action indicates client abandonment. In addition, this action does not address the conflict directly. Option 1 is an aggressive action and does not address the conflict directly.
A nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a roast beef dinner with whole milk as a beverage. Which action should the nurse take?
Rationale: In the Orthodox Jewish tradition, members avoid meat from carnivores, pork products, and certain fish. The nurse would not deliver the food tray to the client and would ask the dietary department to deliver a different meal. Meat and dairy are served separately, thus the dairy-meat combination is not acceptable, making option 2 incorrect. Option 4 is incorrect because pork and pork products are also not allowed in the diet.
A nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter states to the nurse, "My mother has fallen out of bed three times." Which observation by the nurse would indicate the need for intervention to ensure safety?
Rationale: Leaving a side rail down on the bed of an older client increases the risk of falling. The aging process also increases this client's potential for falls; therefore evaluating the safety of the environment is a necessity. Options 1, 2, and 3 identify observations that provide safety to the client.
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
Rationale: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further instruction if the client states to:
Rationale: The client is at risk for impairment of skin integrity resulting from the presence of the catheter, exposure to moisture, and irritation from tape and cleansing solutions. The client should be instructed to use paper or non-allergenic tape to prevent skin irritation and breakdown. It is proper procedure for the client to use aseptic technique and to self-monitor vital signs and weight on a daily basis.
A client with history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if the value reported is:
Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client could experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.
A client has a prescription for valproic acid (Depakene) orally once daily. The nurse plans to:
Rationale: Valproic acid is an anticonvulsant, antimanic, and antimigraine medication. It may be administered with or without food. It should not be taken with an antacid or carbonated beverage because these products will affect medication absorption. The medication is administered at the same time each day to maintain therapeutic serum levels.
A nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which of the following actions, if performed by the client, indicates the need for further teaching?
Rationale: When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. Options 2, 3, and 4 identify the correct actions for preparing NPH and regular insulin.
A nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?
Signs and symptoms of fat overload include fever, leukocytosis, hyperlipidemia, pruritic urticaria, and possibly focal seizures. Hepatosplenomegaly may also be present. Options 2, 3, and 4 are not signs of this complication.
A nurse is caring for a client with cancer of the prostate after a prostatectomy. The nurse provides discharge instructions and plans to include which of the following?
Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A daily fluid intake of 2 to 2.5 L/day should be maintained to limit clot formation and prevent infection. Option 3 is an accurate discharge instruction after prostatectomy.
A health care provider tells the nurse that a potassium-sparing diuretic is being prescribed for the client with congestive heart failure. The nurse reviews the health care provider's prescriptions, expecting that which of the following medications will be prescribed?
Spironolactone (Aldactone
A nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, knowing that the child is in which stage of Erikson's psychosocial stages of development?
ationale: A 2-year-old child, a toddler, is in the autonomy vs. shame and doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions and exerts himself or herself. Trust vs. mistrust characterizes the stage of infancy. Initiative vs. guilt characterizes the preschool age. Industry vs. inferiority characterizes the school-age child.
A female client with carcinoma of the breast is admitted to the hospital for treatment with intravenous vincristine (Oncovin). The client tells the nurse that she has been told by her friends that she is going to lose all her hair. The nurse makes which appropriate response to the client?
"Hair loss may occur, and it will grow back, but it may have a different color or texture." Alopecia (hair loss) can occur following the administration of many antineoplastic medications. Alopecia is reversible, but new hair growth may have a different color and texture.
A health care provider aspirates synovial fluid from a knee joint of a client with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to indicate which finding?
Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.
Atropine sulfate is prescribed for a client with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which of the following, if noted on the client's record, indicates the need to contact the health care provider before administering the medication?
Rationale: Atropine sulfate can cause mydriasis (dilation of the pupil) and cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. Options 1, 2, and 4 are all therapeutic reasons for using the medication.
An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client's fluid imbalance?
A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins. Other findings are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The manifestations noted in options 2, 3, and 4 indicate fluid volume excess
A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. The appropriate nursing response is:
Rationale: Encouraging the client to share feelings with her husband directly addresses the subject of the question. Advising the client to join a support group will not address the client's immediate and individual concerns. The remaining options are blocks to communication and avoid the client's concerns.
A nurse is caring for a client who is hearing-impaired and takes which approach to facilitate communication?
It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but it is important to avoid talking directly into the impaired ear.
A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?
Decrease wheezing Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute.
A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which of the following interventions should be included in the plan of care? Select all that apply
Rationale: Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may gradually begin to ambulate.
