403 PrepU Qs

A client comes to the emergency department with complaints of a suspected wound infection. The client had major surgery 5 days ago. Which would be the nurse's priority action? a. Ask the client to rate the pain on a scale of 1 to 10. b. Assess the client's white blood cell (WBC) count. c. Assess the wound's drainage. d. Take the client's oral temperature.

c. Assess the wound's drainage. Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguinous. An elevated temperature, WBC count, and pain at the incision site are less specific indicators of infection than drainage. The first three signs could be related to other conditions, such as expected postoperative pain, poor wound healing, or pneumonia.

A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which assessment is the priority? 1. vital signs 2. laboratory values 3. neurological status 4. pain in the flank region

3. neurological status Clients experiencing dialysis for the first time often have confusion and even seizures and should be monitored closely. Vital signs and laboratory values are important assessments but do not specifically address dialysis disequilibrium syndrome. Pain in the flank region is not associated with dialysis.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? 1. Administer the medication as ordered. 2. Discontinue the medication. 3. Question the physician about the order. 4. Advise the client to discuss the MI with the physician.

3. Question the physician about the order. Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine sulfate IV by patient-controlled analgesia (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. What should the nurse do next? 1. Discontinue the PCA pump. 2. Administer oxygen. 3. Take the client's blood pressure. 4. Assist the client back to bed.

3. Take the client's blood pressure. The nurse should take the client's blood pressure. She is likely experiencing orthostatic hypotension. The PCA pump does not need to be discontinued because as soon as the blood pressure stabilizes the pain medication can be resumed. Administering oxygen is not necessary unless the oxygen saturation also drops. The client should sit in the chair until the blood pressure stabilizes.

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? 1. impaired color discrimination 2. increased urinary frequency 3. decreased hearing acuity 4. increased appetite

3. decreased hearing acuity Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be ordered. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus.

The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. What should the nurse should do next:? 1. Apply an ice pack to the perineal area. 2. Assess the client's temperature. 3. Have the client take a warm sitz bath. 4. Contact the health care provider (HCP) for orders for an antibiotic.

1. Apply an ice pack to the perineal area. The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the first 24 hours. Although vital signs, including temperature, are important assessments, taking the client's temperature is unrelated to the hematoma and would provide no additional information about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve without further treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide a baseline for subsequent measurements and should notify the HCP of its presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or symptoms of infection.

A nurse is caring for a client in addisonian crisis. Which medication order should the nurse question? 1. potassium chloride 2. normal saline solution 3. hydrocortisone 4. fludrocortisone

1. potassium chloride Since addisonian crisis results in hyperkalemia, administering potassium chloride is contraindicated. Therefore, the nurse should question the order for potassium chloride, making this the correct choice for this question. Because the client is hyponatremic, an order for normal saline solution is appropriate. Hydrocortisone and fludrocortisone are used to replace deficient adrenal cortex hormones.

The nurse assesses a school-age child in the emergency department and finds a respiratory rate of 52 breaths/min, accessory muscle use, wheezing, and an oxygen saturation of 87% on room air. What action will the nurse take first? 1. Ask the parents about the child's medical conditions. 2. Give albuterol (salbutamol) by nebulizer as prescribed. 3. Initiate continuous cardiac monitoring. 4. Apply supplemental oxygen.

4. Apply supplemental oxygen. A client in respiratory distress with a saturation lower than 90% needs to have supplemental oxygen placed immediately, followed by initiation of cardiac monitoring. The other interventions follow these actions.

A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care? 1. monitoring intake and output 2. inserting an indwelling catheter 3. restricting oral intake 4. maintaining bed rest

1. monitoring intake and output Oxytocin has an antidiuretic effect; prolonged IV infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Therefore, the nurse should monitor intake and output closely. It isn't necessary to insert a catheter. Clients in labor do not have oral fluid restrictions. There is no need for the client to maintain complete bed rest.

The nurse is teaching a client and the client's family about the total parenteral nutrition (TPN) that the client is receiving. What information should the nurse include in this teaching? Select all that apply. 1. TPN is administered through a large central blood vessel. 2. The solution contains sugar, protein, and fat for increased calories. 3. The client may experience constipation. 4. Tests to monitor blood and urine glucose levels will be done. 5. The client will need insulin to prevent diabetes.

1. TPN is administered through a large central blood vessel. 2. The solution contains sugar, protein, and fat for increased calories. 4. Tests to monitor blood and urine glucose levels will be done. There is a possibility of abdominal cramping and diarrhea, not constipation, from TPN. Glucose levels will need to be monitored, and some clients may need insulin to regulate blood glucose levels during TPN, but the client will not develop diabetes from TPN.

A client comes to the emergency department reporting sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? 1. kidney 2. ureter 3. bladder 4. urethra

1. kidney The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.

While attempting to obtain a blood sample from a peripherally inserted central catheter (PICC) line with a nonocclusive dressing, the nurse inadvertently dislodges the catheter. The catheter did not come all the way out and is still partially inserted. What should the nurse do first? 1. Change the catheter dressing and document the incident. 2. Secure the catheter and send the client for a chest x-ray. 3. Remove the dressing and push the catheter back in place. 4. Secure the catheter and call the health care provider.

4. Secure the catheter and call the health care provider. If a PICC line is dislodged and does not come all the way out, the health care provider needs to be notified after the line is secured. The health care provider may order a chest x-ray to determine where the tip is located. Changing the dressing and documenting the incident do not address the concern. The nurse should not push the catheter back into place.

A school-age child is being discharged with a diagnosis of rheumatic fever. Which instructions should be included in the teaching plan for the family? a. The child should stay on penicillin and return for a follow-up appointment. b. At home, be sure to keep the child on bed rest. c. All children with rheumatic fever need monthly blood tests. d. The child should stay out of school until the source of the infection is determined.

a. The child should stay on penicillin and return for a follow-up appointment. A child with rheumatic fever should stay on penicillin — either oral daily or an injection monthly — to prevent a recurrence. A follow-up appointment is needed to determine how the child is responding to treatment. Neither bed rest nor monthly blood tests will be ordered for all children. Rheumatic fever is caused by group A beta-hemolytic streptococci, so the source of the infection is already known.

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus? 1. universal precautions 2. droplet precautions 3. contact precautions 4. airborne precautions

2. droplet precautions Group-A beta-hemolytic streptococcal infections are spread through droplets. Standard and contact precautions would not be sufficient to decrease transmission. Group-A beta-hemolytic streptococcal infections do not require specialized masks.

A 10-year-old child is taking high doses of aspirin. Which finding indicates the child is experiencing early salicylate toxicity? 1. chest pain 2. pink-colored urine 3. slowed pulse rate 4. dizziness

4. dizziness Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use. Pink-colored urine, a slowed pulse rate, and chest pain, rarely occurring in children, are not associated with salicylate toxicity.

The client is diagnosed with tonic-clonic seizures and is ordered phenytoin. In teaching the client about the common side effects of phenytoin, what information should the nurse include? Select all that apply. 1. "Phenytoin can cause swollen gums." 2. "Phenytoin can cause constipation." 3. "Phenytoin can cause slurred speech." 4. "Phenytoin can cause urinary frequency." 5. "Phenytoin can cause photosensitivity."

Phenytoin is a anticonvulsant. Adverse effects include constipation, slurred speech, gingival hyperplasia, confusion, nausea and vomiting. Urinary frequency and photosensitivity is not included in the adverse effects of phenytoin.

The nurse attempts to obtain a blood specimen from an implanted port. The port does not have blood return. What should the nurse do next? a. Remove the implanted port. b. Send the client to get a chest x-ray. c. Have the client change positions. d. Change the dressing on the implanted port.

c. Have the client change positions. If an implanted port does not have blood return, having the client change position, performing the Valsalva maneuver, and raising or lowering the head of the bed can promote blood return. The port should not be removed; the access needle may need to be removed and reinserted depending on the facility policy. A chest x-ray may be required but is not what the nurse should do first. Changing the dressing may not help with blood return.

Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data? a. The client is developing an infection of the urinary tract. b. The mucus is caused by elevated levels of glucose in the urine. c. These findings are normal for a client with an ileal conduit. d. There is irritation of the stoma.

c. These findings are normal for a client with an ileal conduit. A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection or stomal irritation. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine.

A nurse is reviewing discharge instructions with the parents of an adolescent who sustained a head injury to the frontal lobe of the brain. When discussing possible consequences of the injury, which of the following is the most important information to give the parents? a. "Your child may exhibit drastic personality changes." b. "Your child may develop sudden problems with vision." c. "Your child will gradually lose the ability to hear." d. "Your child may mention unusual numbness and tingling."

a. "Your child may exhibit drastic personality changes." The frontal lobe regulates personality and judgment. The occipital lobe regulates vision. The temporal lobe regulates hearing. The parietal lobe regulates sensation.

The nurse must administer a unit of packed red blood cells to a 4-year-old child. The child's blood type is Type B Rh factor positive. When the unit of blood arrives, it is labeled as Type O Rh factor negative. What is the appropriate action for the nurse to take? 1. Begin the administration of the blood as ordered. 2. Return the blood and order a new unit of Type B. 3. Document the error with an incident report. 4. Have the child's blood retested for blood type.

1. Begin the administration of the blood as ordered. Type O Rh negative blood is the universal donor and can be administered to a child who is Type B. As long as the crossmatch report confirms "OK to transfuse," there would be no need to return this unit to the blood bank. This should not be considered an error and would not be documented as such. There is no indication for retesting the child's blood type.

A nurse admits an infant diagnosed with pyloric stenosis. What is the nurse's priority intervention? 1. Weigh the infant. 2. Check urine specific gravity. 3. Place an I.V. catheter. 4. Change the infant and weigh the diaper.

1. Weigh the infant. Weighing the infant would be done first so a baseline weight can be established and weight changes can be evaluated. After a baseline weight is obtained, an I.V. catheter can be placed because oral feedings generally aren't given. Infants with pyloric stenosis are usually dehydrated, so weighing the diaper or checking the specific gravity, though important, are not a priority.

The nurse is assessing a client who sustained blunt chest trauma from a motor vehicle collision. There are no obvious signs of bleeding. The provider diagnoses the client with cardiac tamponade. What assessment data would the nurse anticipate? Select all that apply. 1. apical pulse of 156 2. blood pressure of 62/48 3. muffled heart sounds 4. peaked t-waves 5. jugular vein distention

1. apical pulse of 156 2. blood pressure of 62/48 3. muffled heart sounds 5. jugular vein distention Apical pulse of 156, blood pressure of 62/48, muffled heart sounds, and jugular vein distention are associated with a diagnosis of cardiac tamponade. Peaked t-waves are associated with hyperkalemia.

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? 1. diluting the chemicals 2. applying sterile dressings 3. applying topical antibiotics 4. debriding and grafting the burns

1. diluting the chemicals Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

Which urine characteristics would the nurse anticipate in a client with diabetes insipidus? Select all that apply. 1. pale 2. concentrated 3. specific gravity between 1.01 and 1.015 4. specific gravity more than 1.005 5. specific gravity less than 1.005 6. pink-tinged

1. pale 5. specific gravity less than 1.005 A client with diabetes insipidus will have excessive urine output that is pale in color, with a specific gravity of less than 1.005. A pink tinge suggests hematuria, which does not accompany diabetes insipidus.

Which sign or symptom is related primarily to small-bowel obstruction rather than large-bowel obstruction? 1. profuse vomiting 2. cramping abdominal pain 3. abdominal distention 4. high-pitched bowel sounds above the obstruction

1. profuse vomiting Profuse vomiting is the classic sign of small-bowel obstruction and rarely occurs with large-bowel obstruction. Abdominal discomfort is present in both small- and large-bowel obstructions. Abdominal distention occurs with both small- and large-bowel obstruction but is more common in large-bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.

The nurse is assessing an infant with neonatal bronchopulmonary dysplasia (chronic lung disease). Which symptoms would the nurse expect to find? Select all that apply. 1. tachypnea 2. bradypnea 3. hyperexpansion on chest X-ray 4. rapid weight gain 5. wheezing

1. tachypnea 3. hyperexpansion on chest X-ray 5. wheezing The physical exam of an infant with neonatal chronic lung disease often reveals tachypnea and wheezing. The chest X-ray shows hyperinflation as the disease becomes more severe. Infants often fail to gain weight.

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that 1. the infant should respond to gentle tactile or verbal stimulation. 2. the infant's reflexes will be decreased or absent. 3. the infant will remember the procedure. 4. the infant will need a patient-controlled analgesia (PCA) pump during sedation.

1. the infant should respond to gentle tactile or verbal stimulation. An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren't used during sedation.

A client scheduled for hemodialysis is prescribed an oral antihypertensive daily. What is the correct action by the nurse regarding the medication? 1. Administer it prior to the hemodialysis treatment. 2. Administer it after the hemodialysis treatment. 3. Contact the health care provider for a prescription to hold it on dialysis days. 4. Administer it during the hemodialysis treatment

2. Administer it after the hemodialysis treatment. The nurse should administer the medication after the hemodialysis treatment to prevent a hypotensive episode. The medication should not be held on the days the client has dialysis unless the client's blood pressure contraindicates giving the medication. Administering the medication prior to the treatment may lead to the client becoming hypotensive during dialysis or having the medication filtered out of the bloodstream during the hemodialysis treatment.

The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed? 1. Sterile procedure, droplet precautions 2. Clean procedure, universal precautions 3. Clean procedure, contact precautions 4. Sterile procedure, airborne precautions

2. Clean procedure, universal precautions Site care for a recently placed G-tube is a clean procedure, not a sterile procedure. Care should be taken not to introduce bacteria into the fresh site, but sterile gloves and sterile procedure is not necessary or recommended. Universal precautions are required, as the nurse will come into contact with blood and/or bodily fluids while cleaning around the G-tube. Droplet, contact, and airborne precautions are not indicated, because these are for a variety of infectious diseases such as methicillin-resistant Staphylococcus aureus, influenza, measles, meningitis and tuberculosis, not for wound care.

A client has a respiratory rate of 4 breaths/min. What are this nurse's priority assessments? 1. Arterial blood gas (ABG) and breath sounds 2. Level of consciousness and a pulse oximetry value 3. Breath sounds and reflexes 4. Pulse oximetry value and heart sounds

2. Level of consciousness and a pulse oximetry value This nurse should first attempt to rouse the client to increase the respiratory rate. Pulse oximetry and breath sounds should be assessed, and the provider informed of the findings. An ABG analysis may be ordered to determine specific carbon dioxide and oxygen levels, which would indicate the effectiveness of ventilation. An assessment of reflexes and heart sounds would be part of the more extensive examination done after the respiratory rate has stabilized.

A child diagnosed with bacterial meningitis has been admitted to the unit. What is the priority nursing action? 1. providing pain control 2. administering intravenous antibiotics 3. reducing environmental stimuli 4. avoiding lifting the client's head

2. administering intravenous antibiotics Bacterial meningitis is a medical emergency that requires immediate treatment with antibiotics. If not treated rapidly, it may lead to brain damage, deafness, stroke, and death. All the other actions are important but only secondary to administering antibiotics.

The nurse is counseling an expectant teen mother on the benefits of breastfeeding. What are the expected benefits of breastfeeding? Select all that apply. 1. decreased risk of prematurity 2. increased chance of higher intelligence in the baby 3. decreased risk of mastitis 4. decreased risk of Sudden Infant Death Syndrome (SIDS) 5. decreased risk of childhood obesity 6. increased chance of return to pre-pregnant weight

2. increased chance of higher intelligence in the baby 4. decreased risk of Sudden Infant Death Syndrome (SIDS) 5. decreased risk of childhood obesity Studies have shown an increase in the intelligence scores of breastfed infants, and a decrease in the risk of SIDS and childhood obesity. The decision to breastfeed has no impact on the risk of delivering prematurely. Mastitis commonly occurs in breastfeeding mothers when bacteria enters the breast through a cracked nipple. Studies of the overall effect of breastfeeding on the return of the mothers to their pre-pregnancy weight are inconclusive.

The emergency room nurse is caring for a client who fell, breaking the tibia. The nurse determines that the client understands the risk of compartment syndrome when knowing to report which early symptom following treatment? 1. heat 2. paresthesia 3. skin flushing 4. swelling

2. paresthesia Compartment syndrome is the compression of the nerves, blood vessels, and muscle inside a closed space. It may occur after trauma to an extremity. The earliest sign of compartment syndrome is paresthesia. This is one of the "5 Ps" of compartment syndrome. The others are pain out of proportion to the injury, pallor and delayed capillary refill, normal-to-absent pulses in distal extremity, and paralysis in the limb (a late sign). Flushing, swelling, and heat are not associated with compartment syndrome.

After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the parent makes which statement? 1. "There are congenital polyps obstructing the colon." 2. "A section of the colon is constricted." 3. "The nerves at the end of the large colon are missing." 4. "There is weakened area in the colon that is inflamed."

3. "The nerves at the end of the large colon are missing." The primary defect in Hirschsprung's disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are missing. Constipation is caused by decreased peristalsis, not a physical obstruction like polyps. The colon typically enlarges giving rise to the name "megacolon" versus being constricted. Weakened areas of the colon are associated with diverticulosis.

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? 1. A client with a history of recurrent candidiasis 2. A client who had her first pregnancy before the age of 20 3. A client infected with the human papillomavirus (HPV) 4. A client who has used oral contraceptives for 27 years

3. A client infected with the human papillomavirus (HPV) HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer.

Which nursing intervention is essential while caring for an infant with cleft lip or palate? 1. Avoid encouraging breastfeeding. 2. Cradle the infant horizontally while feeding. 3. Involve the parents in feeding as soon as possible. 4. Choose a regular nursery nipple for feedings

3. Involve the parents in feeding as soon as possible. The sooner the parents become involved, the quicker they're able to determine the method of feeding best suited for them and their infant. Breastfeeding, like bottle feeding, may be difficult but can be facilitated if the mother is supported in this decision. If the cleft isn't severe, breastfeeding may be easier than other feeding techniques because the human nipple conforms to the shape of the infant's mouth. Feedings are usually given in the upright position to prevent formula from coming through the nose. Various special nipples have been developed for infants with cleft lip or palate. A regular nursery nipple is not effective.

An adolescent sustains a head injury and develops diabetes insipidus. The healthcare provider orders desmopressin, 10 mcg subcutaneously. When does the nurse assess the client to determine the need for an additional dose? 1. 15 to 30 minutes 2. 30 minutes to 2 hours 3. 2 to 4 hours 4. 4 to 7 hours

4. 4 to 7 hours The minimum required dose is given to avoid water retention and hyponatremia. Control of polyuria and electrolytes is the goal. Another dose is not administered until the client has another episode of brisk polyuria and diuresis, indicating the initial dose is no longer effective. The drug's half life via this route is 3 hours, indicating the drug will stop working in about 6 hours.

A nurse is caring for clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes? 1. A client who reports headache and fever 2. A client who reports vaginal and urethral discharge 3. A client who reports dysuria and lymphadenopathy 4. A client who reports genital pruritus and paresthesia

4. A client who reports genital pruritus and paresthesia Pruritus and paresthesia as well as redness of the genital area are prodromal symptoms of recurrent herpes infection. These symptoms occur 30 minutes to 48 hours before the lesions appear. Headache and fever are symptoms of viremia associated with the primary infection. Vaginal and urethral discharge are also a local sign of primary infection. Dysuria and lymphadenopathy are localized symptoms of a primary infection that may also occur with recurrent infection.

A child with Wilms' tumor has had a kidney removed, and is now receiving chemotherapy. What priority information should the nurse share with this child's family at the time of discharge? 1. Avoid contact sports. 2. Limit fluid intake as ordered. 3. Decrease sodium intake. 4. Avoid contact with other children.

4. Avoid contact with other children. Because the child has only one kidney, certain precautions are recommended to prevent injury to the remaining kidney. Fluid intake is essential for renal function, and should not be decreased. The child's sodium intake shouldn't be reduced. Avoiding other children is unnecessary, may make the child feel self-conscious, and may lead to regressive behavior.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse? 1. Increase the suction level of the chest tube. 2. Connect the client to a new chest tube system. 3. Clamp the chest tube and document the response. 4. Further assess the client for reinflation of the lung.

4. Further assess the client for reinflation of the lung. A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube.

The nurse assesses the postpartum client and notes blood gushing from the vagina, pallor, and a rapid, thready pulse. What is the nurse's priority intervention? 1. Insert an indwelling urinary catheter. 2. Call the healthcare provider. 3. Check the blood pressure. 4. Massage the fundus.

4. Massage the fundus. Uterine atony can contribute to postpartum hemorrhage, which results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. The priority measure to correct postpartum hemorrhage is to massage the fundus. Emptying the bladder via indwelling catheter and checking vital signs are not priorities. Massaging the fundus will increase uterine tone and decrease vaginal bleeding. The healthcare provider will have to be called, but the nurse must first intervene. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus.

The nurse observes a new parent give an oral medication to a 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which choice is the nurse's best action? 1. Instruct the parent to instill a small amount of the medication inside the baby's cheek. 2. Praise the parent's technique of giving the medication. 3. Have the parent lay the infant flat, restraining the arms, while giving the medication. 4. Demonstrate to the parent ways to prop the infant in a sitting position for medication administration.

1. Instruct the parent to instill a small amount of the medication inside the baby's cheek. The parent's technique of instilling the medication in the back of the throat is not correct and could cause the infant to choke. The nurse should instruct the parent to instill a small amount at a time inside the infant's cheek. The parent should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. Propping a 4-month-old infant is not appropriate. The infant cannot sit unsupported even in a seated position. Administering medication to an infant lying flat could cause choking and aspiration.

A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse's understanding of the case manager? 1. The case manager collaborates care among all health care partners with the client in the center. 2. The case manager is responsible for all the healthcare choices and all decisions should start with the case manager. 3. The case manager cares for the whole client including the dietary and psychosocial needs. 4. The case manager is aware of all needs of the client during the hospitalization and provides for them after the client returns home.

1. The case manager collaborates care among all health care partners with the client in the center. Explanation: Case management is a collaborative process. Case managers work closely with physicians, nurses, social workers, and a wide range of medical and nonmedical professionals. Case managers work to meet complex patient needs. They make provisions for current and future needs of patients. Case management nurses promote quality care that encourages appropriate use of available resources.

A client with bipolar disorder tells the nurse that she just found out she is pregnant, and is concerned because she takes lithium. What is the most important information for the nurse to provide to this client? 1. Use of lithium usually results in serious congenital problems. 2. Thyroid problems can occur in the first trimester of the pregnancy. 3. Lithium causes severe urine retention and increased risk of toxicity. 4. Women who take lithium are very likely to have a spontaneous abortion.

1. Use of lithium usually results in serious congenital problems. Use of lithium during pregnancy will result in congenital defects, especially cardiac defects. Thyroid problems don't occur in the first trimester of the pregnancy. In lithium toxicity, a condition called nontoxic goiter may occur. An adverse effect of lithium is polyuria, not urine retention. The rate of spontaneous abortion for women taking lithium is no greater than for nonusers.

A client is prescribed furosemide to manage heart failure. What laboratory values should the nurse monitor while the client receives this medication? Select all that apply. 1. complete blood count 2. serum potassium 3. prothrombin time (PT) 4. thrombin time 5. international normalized ratio

1. complete blood count 2. serum potassium -Complete blood count should be monitored, because furosemide can cause agranulocytosis, anemia, leukopenia, and thrombocytopenia. -Because loop diuretics such as furosemide promote excretion of potassium, the nurse should also monitor serum potassium levels. Potassium replacement therapy may be necessary to prevent hypokalemia. Thrombin time, PT, and INR do not have to be monitored in a client receiving furosemide.

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? 1. the importance of watching for signs of hyperglycemia 2. the need to adjust the steroid dose based on dietary intake and exercise 3. To notify the health care provider (HCP) when the blood pressure is suddenly high 4. how to decrease the dose of the corticosteroids when the client experiences stress

1. the importance of watching for signs of hyperglycemia Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise; insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism, resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone, and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state, which is a medical emergency manifested by signs of shock.

The nurse assesses a client who has just received morphine sulfate. The client's blood pressure is 90/50 mm Hg; pulse rate, 58 bpm; and respiration rate, 4 breaths/min. What should the nurse do first? 1. Call the rapid response team. 2. Administer naloxone hydrochloride. 3. Start oxygen at 2 liters/min per nasal cannula. 4. Obtain a stat ECG.

2. Administer naloxone hydrochloride. The nurse should first administer naloxone hydrochloride, which is the antidote for morphine sulfate. The signs of overdose on morphine sulfate are a respiration rate of 2 to 4 breaths/min, bradycardia, and hypotension. If the client does not respond, the nurse can call the rapid response team. The client's respirations should improve after receiving the naloxone. Obtaining an ECG is not the first priority for reversing the effects of the morphine.

A client is having peritoneal dialysis. During the exchange, the nurse observes that the solution draining from the client's abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place. What clinical judgment should the nurse make about the blood-tinged drainage? 1. It is expected with a permanent peritoneal catheter. 2. It indicates abdominal blood vessel damage. 3. It can indicate kidney damage. 4. It is caused by too-rapid infusion of the dialysate.

2. It indicates abdominal blood vessel damage. Because the client has a permanent catheter in place, blood-tinged drainage should not occur. Persistent blood-tinged drainage could indicate damage to the abdominal vessels, and the health care provider (HCP) should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys. Too-rapid infusion of the dialysate can cause pain, not blood-tinged drainage.

A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety? 1. Discontinue the TPN infusion. 2. Start an IV infusion of normal saline. 3. Administer PRBCs in the same IV as the TPN. 4. Wait until the TPN infusion is completed, and use the same IV line to infuse the PRBCs.

2. Start an IV infusion of normal saline. The nurse administers the PRBCs using a separate infusion line and appropriate tubing, with normal saline as the priming solution. It is not necessary to discontinue the TPN infusion or wait until the TPN infusion is completed.

The nurse plans care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first? 1. an 18-year-old G2 P2 with an uncomplicated spontaneous vaginal birth 12 hours ago who has abdominal cramps 2. a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm 3. a 16-year-old G1 P1 with a caesarean birth 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h; reflexes are 2+, and the nurse's notes indicate she has a headache; vital signs are T 99.4 F (37.4 C), P 88, R 20, BP 128/86 mm Hg 4. an 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain; vital signs are T 99.8 F (37.7 C), P 96, R 22

2. a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm The criteria for hemorrhage is saturating one pad per hour. The 35-year-old who delivered 4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration, which would be the source of the bleeding. She needs to be evaluated first, based on the bleeding. The 18-year-old who has abdominal cramps is within normal limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will need pain medication. The 16-year-old status post cesarean birth on magnesium sulfate is stable with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a postpartum client. The headache is the one area of concern for this client. The 18-year-old who is 2 days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk developing within her system. The vital signs for this client are slightly elevated, but this may be from the milk coming in and would require nursing evaluation but is not emergent.

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? 1. fluid balance 2. anaphylactic reaction 3. pain 4. altered level of consciousness

2. anaphylactic reaction The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the health care provider. Usually, an antihistamine such as diphenhydramine hydrochloride) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.

A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which test based on the client's concerns? 1. culture and sensitivity 2. occult blood and organisms 3. ova and parasites 4. fat and undigested food

2. occult blood and organisms Occult blood in the stool could indicate active bleeding; the stool should also be examined for microorganisms to detect early infections that could easily become systemic by spreading through the damaged mucosa. Culture and sensitivity is reflective for urine and potential infection. Parasite testing is not correct because this client has a chronic bowel problem. Fat and undigested food has no relation to the current problem.

The client is brought to the emergency department (ED) via ambulance. A family member was talking with the client and suddenly the client began to slur words, and could not move their right side. The healthcare provider diagnoses a left-sided cerebrovascular accident (CVA) and orders a thrombolytic medication. Which medication would the nurse anticipate the healthcare provider to order? 1. warfarin sodium 2. streptokinase 3. heparin sodium 4. phytonadione

2. streptokinase Streptokinase is an enzyme used to break down red blood cells. The other medications are not appropriate in this scenario. Warfarin sodium and heparin sodium are both used to inhibit antithrombin III. Phytonadione is necessary for clot formation.

A nurse administered neutral protamine Hagedorn (NPH) insulin to a client with diabetes mellitus at 7 a.m. (0700). At what time should the nurse expect the client to be most at risk for hypoglycemia? 1. 10 a.m. (1000) 2. noon (1200) 3. 4 p.m. (1600) 4. 10 p.m. (2200)

3. 4 p.m. (1600) NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m. (0700), the client is at greatest risk for hypoglycemia from 3 p.m. (1500) to 7 p.m. (1900).

A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? 1. hypercalcemia 2. hyperphosphatemia 3. hypokalemia 4. hypernatremia

3. hypokalemia Hypokalemia occurs when insulin administration causes glucose and potassium to move into the cells. Insulin administration doesn't directly affect calcium levels. Hypophosphatemia — not hyperphosphatemia — may occur with insulin administration because phosphorus enters the cells with insulin and potassium. Insulin administration doesn't directly affect sodium levels.

A physician prescribes several drugs for a client admitted to the emergency department with Laennec's cirrhosis. Which drug order should the nurse question? 1. folic acid 2. ketorolac 3. warfarin 4. vitamin K

3. warfarin Laennec's cirrhosis is caused by excessive alcohol use. The client is at risk for bleeding related to the inability of the liver to alteration in clotting factors; therefore, warfarin is contraindicated. Folacin or folic acid and vitamin K are all appropriate for this client due to vitamin deficiencies caused by cirrhosis. Ketorolac is a nonopioid analgesic and is appropriate for pain control in this client.

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first? 1. Call the neurosurgeon. 2. Place the client in the Trendelenburg position. 3. Consult the neurologic Clinical Nurse Specialist (CNS). 4. Activate the Rapid Response Team (RRT).

4. Activate the Rapid Response Team (RRT). RRTs, or medical emergency teams, provide a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. Calling the neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk.

The client with Alzheimer's disease has been prescribed donepezil 5 mg at bedtime. Which instructions should the nurse give to the client's caretaker? 1. Take her mother to the clinic next week for blood work. 2. Give her mother an extra dose if needed at night. 3. Observe her mother for signs of constipation. 4. Avoid suddenly stopping the medication.

4. Avoid suddenly stopping the medication. -Abrupt cessation of donepezil may result in rapid deterioration of client functioning. -Donepezil does not cause liver toxicity, so monitoring of blood serum levels is not necessary. -Extra doses of donepezil are not given on an as-needed basis. -Donepezil is more likely to produce diarrhea than constipation.

The nurse is caring for an immunocompromised premature neonate who is prescribed bolus feedings per a gastrostomy tube (G-tube). What action(s) does this include? Select all that apply. a. Use an enteral feeding syringe with the plunger removed to deliver the formula. b. Ensure tubing is completely emptied of formula prior to clamping at end of feeding. c. Provide the neonate with a pacifier to use during the bolus feeding procedure. d. Begin feeding with the syringe elevated as high as possible, and lower gradually. e. Flush the tube with room temperature purified water after feeding is completed.

A, C, E When administering a prescribed bolus feeding of a neonate with a G-tube, the nurse uses an enteral syringe with the plunger removed attached to the end of the enteral tube or extension set. Gravity alone should be used and the formula allowed to flow slowly by starting at a lower elevation and elevating slowly to control the flow. Starting at the highest elevation may deliver the formula too quickly. The nurse should not allow the syringe and tubing to empty completely as this will allow air to enter the stomach. Infants who can suck should be offered a pacifier during feedings to stimulate normal feeding muscle use and promote secretion of digestive enzymes. After the feeding, the tubing should be flushed with the prescribed volume of water and in the case of an immunocompromised neonate, purified water should be used.

A teaching care plan to prevent transmission of respiratory syncytial virus (RSV) should include what information? Select all that apply. a. The virus can be spread by direct contact. b. The virus can be spread by indirect contact. c. Palivizumab is recommended to prevent RSV for all toddlers in daycare. d. The virus is typically contagious for 3 weeks. e. Older children seldom spread RSV. f. Frequent handwashing helps reduce the spread of RSV.

a. The virus can be spread by direct contact. b. The virus can be spread by indirect contact. f. Frequent handwashing helps reduce the spread of RSV. RSV can be spread through direct contact such as kissing the face of an infected person, and it can be spread through indirect contact by touching surfaces covered with infected secretions. Handwashing is one of the best ways to reduce the risk of disease transmission. Palivizumab can prevent severe RSV infections but is only recommended for the most at-risk infants and children. RSV is typically contagious for 3 to 8 days. RSV frequently manifests in older children as cold-like symptoms. Infected school-age children frequently spread the virus to other family members.

A child with cystic fibrosis is receiving gentamicin. Which nursing action is most important? a. monitoring intake and output b. obtaining daily weights c. monitoring the client for indications of constipation d. obtaining stool samples for hemoccult testing

a. monitoring intake and output Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because a. the client is experiencing heart failure. b. the client is going into cardiogenic shock. c. the client shows signs of aneurysm rupture. d. the client is in the early stage of right-sided heart failure.

b. the client is going into cardiogenic shock. This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Prior to surgery, what comment by the client indicates that the client understands the procedure? a. "This is a temporary procedure that can be reversed later." b. "I will urinate through my rectum." c. "My urine will come out through an opening on my abdomen." d. "My urine will go from my bladder into a drainage bag."

c. "My urine will come out through an opening on my abdomen." An ileal conduit is a permanent urinary diversion in which a portion of the ileum is surgically resected and one end of the segment is closed. The ureters are surgically attached to this segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to form the stoma. The client must wear a pouch to collect the urine that continually flows through the conduit. The bladder is removed during the surgical procedure, and the ileal conduit is not reversible. Diversion of urine to the sigmoid colon is called a ureteroileosigmoidostomy. An opening in the bladder that allows urine to drain externally is called a cystostomy.

When a client is recovering as expected from spinal anesthesia, the nurse should assess: a. level of consciousness. b. rate and depth of respirations. c. rate of capillary refill in the toes. d. degree of response to pinpricks in the legs and toes.

d. degree of response to pinpricks in the legs and toes. Return of sensation in the toes and legs marks recovery from spinal anesthesia. The client receiving spinal anesthesia is conscious, so level of consciousness does not need to be assessed. The client's respiratory status is not affected by spinal anesthesia. Capillary refill time is an indicator of circulatory status, not neurologic status.

When teaching an adolescent with a seizure disorder who is receiving valproic acid, the nurse should instruct the client to immediately report which sign or symptom to the health care provider (HCP)? 1. diarrhea 2. loss of appetite 3. jaundice 4. sore throat

3. jaundice A toxic effect of valproic acid is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the HCP as soon as possible. Diarrhea and sore throat are not common side effects of this drug. Increased appetite is common with this drug.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? a. weigh the client. b. test urine for ketones. c. assess vital signs. d. administer oral hydrocortisone.

c. assess vital signs. Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until the client is stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in their urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

The maximum transfusion time for a unit of packed red blood cells (RBCs) is 1. 1 hour. 2. 2 hours. 3. 4 hours. 4. 6 hours.

3. 4 hours. A unit of packed RBCs may be transfused over a period of 1 to 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. The nurse should discard any blood not given within this time, or return it to the blood bank, in accordance with facility policy.

A nurse is teaching a group of women health promotion strategies. Which activities are primary prevention strategies? Select all that apply. 1. proper use of sunscreen 2. weight-bearing exercises 3. breast self-examinations 4. importance of Papanicolaou (Pap) smear 5. increased intake of vegetables and whole grains

1. proper use of sunscreen 2. weight-bearing exercises 5. increased intake of vegetables and whole grains Primary prevention strategies are used to prevent/reduce risk of disease before it occurs such as by using sunscreen to reduce risk of skin cancer; doing weight-bearing exercises to prevent osteoporosis; increasing intake of vegetables and whole grains to reduce cancer risk. Breast self-examinations and Pap smears are secondary prevention because they focus on screening.

A physician orders gentamicin sulfate, 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least: 1. 5 minutes. 2. 10 minutes. 3. 20 minutes. 4. 30 minutes.

4. 30 minutes. The nurse should infuse gentamicin sulfate I.V. over at least 30 minutes. Infusing the drug more rapidly may increase the client's risk of adverse reactions.

The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? a. The client verbalizes the understanding that physical activity must be curtailed. b. The client will place an aspirin in the drainage pouch to help control odor. c. The client demonstrates how to catheterize the stoma. d. The client will empty the drainage pouch frequently throughout the day.

d. The client will empty the drainage pouch frequently throughout the day. It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.

The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed? a. adhesive strips b. petrolatum gauze c. 4 x 4 gauze d. No dressing is necessary.

b. petrolatum gauze Gauze saturated with petrolatum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dry dressings or adhesive strips are not used.

Which abnormal blood value would not be improved by dialysis treatment? 1. elevated serum creatinine level 2. hyperkalemia 3. decreased hemoglobin concentration 4. hypernatremia

3. decreased hemoglobin concentration 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.

A client is receiving vincristine. What should the nurse instruct the client to do when taking this drug? 1. Use loperamide for diarrhea. 2. Restrict fluids to 1,500 mL/day. 3. Follow a low-fiber, bland diet. 4. Take a stool softener daily.

4. Take a stool softener daily. A side effect of vincristine is constipation, and a bowel protocol should be considered. Loperamide is used to treat diarrhea. Fluids should be encouraged, along with high-fiber foods to prevent constipation.

The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed? a. Sterile procedure, droplet precautions b. Clean procedure, universal precautions c. Clean procedure, contact precautions d. Sterile procedure, airborne precautions

b. Clean procedure, universal precautions Site care for a recently placed G-tube is a clean procedure, not a sterile procedure. Care should be taken not to introduce bacteria into the fresh site, but sterile gloves and sterile procedure is not necessary or recommended. Universal precautions are required, as the nurse will come into contact with blood and/or bodily fluids while cleaning around the G-tube. Droplet, contact, and airborne precautions are not indicated, because these are for a variety of infectious diseases such as methicillin-resistant Staphylococcus aureus, influenza, measles, meningitis and tuberculosis, not for wound care.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? a. at the top of the wound b. in the middle of the wound c. at the base of the wound d. over the total wound

c. at the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

When planning care for a client with hepatitis A, the nurse should review lab reports for which lab value? 1. prolonged prothrombin time 2. decreased blood glucose level 3. elevated serum potassium level 4. decreased serum calcium level

1. prolonged prothrombin time The prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies. Blood glucose, serum potassium, and serum calcium levels are not affected by hepatitis.

The nurse should monitor the client with Cushing's disease for which finding? 1. postprandial hypoglycemia 2. hypokalemia 3. hyponatremia 4. decreased urine calcium level

2. hypokalemia Sodium retention is typically accompanied by potassium depletion. Hypertension, hypokalemia, edema, and heart failure may result from the hypersecretion of aldosterone. The client with Cushing's disease exhibits postprandial or persistent hyperglycemia. Clients with Cushing's disease have hypernatremia, not hyponatremia. Bone resorption of calcium increases the urine calcium level.

A client, age 50, visits the physician for a routine checkup. The history reveals that the client was diagnosed with a spinal curvature at age 45. The nurse knows that life-threatening complications can occur if the progressive spinal curvature exceeds 65 degrees. Which region of the spine should the nurse assess for complications? a. Cervical b. Thoracic c. Lumbar d. Sacral

b. Thoracic The nurse should assess the thoracic region of the spine because a progressive curvature of more than 65 degrees in this region may lead to cardiopulmonary failure as well as less serious signs and symptoms, such as fatigue, back pain, decreased height, and cosmetic deformity. Although a curvature may affect any part of the spine, life-threatening complications aren't associated with curvature of the cervical, lumbar, or sacral regions.

A client is scheduled for an elective splenectomy. What is the last thing the nurse should determine before the client goes to surgery? The client has: a. voided completely. b. signed the consent. c. vital signs recorded. d. the name band on the wrist.

c. vital signs recorded. An elective surgical procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for. The first assessment that will be completed in the preoperative holding area or operating room will be the client's vital signs. -The client should have emptied the bladder before receiving preoperative medications so that the bladder is empty when it is time for transport into the operating room. -The client should have signed the consent before the transport time so that if there were any questions or concerns there was time to meet with the surgeon. -The consent form must be signed before any sedative medications are given. -The client's name band should be placed as soon as the client arrives in the perioperative setting, and it remains in place through discharge.

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? a. hypercalcemia b. hypernatremia c. hypermagnesemia d. hyperkalemia

d. hyperkalemia Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination does not help reverse the effects of hypercalcemia, hypernatremia, or hypermagnesemia.

A child is in the emergency department with suspected epiglottitis and has been ordered an X-ray to confirm the diagnosis. The nurse would prepare the child for X-ray by which methods? a. in radiology, transported by wheelchair, accompanied by a nurse b. in radiology, transported by stretcher, accompanied by a nurse c. in surgery, by portable X-ray d. in the emergency department, by portable X-ray

d. in the emergency department, by portable X-ray The child is at risk for obstruction related to the swollen epiglottis. The nurse should not move the child, keep a careful watch, and get a portable X-ray in the emergency department.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? a. bradycardia b. tachycardia c. increased blood pressure d. reduced cardiac output

d. reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

The client has an incision on the left leg that is draining. The healthcare provider has ordered the client to have graduated compression stockings applied. What should the nurse do first before applying the stockings? 1. Cover the draining incision with a dressing. 2. Question the healthcare provider's order because of the drainage. 3. Apply the stocking only to the unaffected leg. 4. Obtain assistance to help maneuver the stocking over the incision.

1. Cover the draining incision with a dressing. When applying and removing stockings from a leg with an incision, the nurse should be careful not to hit or put pressure on the incision. If the incision is draining a bandage can be applied over the draining area. If the stocking becomes soiled it should be removed and a new dressing should be applied before applying a new, clean stocking. The soiled stocking should be washed and dried before using again. There is no need to notify the healthcare provider to question the order because it is correct to apply a graduated compression stocking over an incision. The purpose is to prevent a deep vein thrombosis. The client may or may not need to be medicated prior to applying the stockings. Assistance generally is not needed.

A nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are a. tracheal. b. fine crackles. c. coarse crackles. d. friction rubs.

b. fine crackles. Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.

On initial assessment of a 7-year-old child with rheumatic fever, which finding would require contacting the primary care provider immediately? 1. heart rate of 150 bpm 2. swollen and painful knee joints 3. twitching in the extremities 4. red rash on the trunk

1. heart rate of 150 bpm A heart rate of 150 bpm is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 bpm. Swollen and painful joints (e.g., the knee), twitching in the extremities (chorea), and a red rash on the trunk are characteristic findings in the child with rheumatic fever and do not require immediate primary care provider notification.

Which signs and symptoms accompany a diagnosis of pericarditis? a. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) b. low urine output secondary to left ventricular dysfunction c. lethargy, anorexia, and heart failure d. pitting edema, chest discomfort, and nonspecific ST-segment elevation

a. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction. Lethargy, anorexia, heart failure and pitting edema do not result from acute renal failure.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. How should the nurse document these findings? a. heart rate irregular with S3 b. heart rate irregular with S4 c. heart rate irregular with aortic regurgitation d. heart rate irregular with mitral stenosis

a. heart rate irregular with S3 An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex, and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.

The nurse is administering adenosine to a client with supraventricular tachycardia. What is the expected therapeutic response? 1. a short period of asystole 2. a brief episode of ventricular tachycardia 3. an increase in blood pressure 4. A brief feeling of numbness and tingling of extremities

1. a short period of asystole The expected response to this medication is a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain followed by a return to normal sinus rhythm. It is used to convert dysrhythmias to normal sinus rhythm and should not cause ventricular tachycardia. Numbness and tingling of extremities is not an expected side effect.

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Which statement made by the client indicates understanding of discharge teaching? 1. "I'll continue to take my antacid even if I feel better." 2. "I'll take my antacid in the morning with my other medications." 3. "I should not take antacids with magnesium, because I have a heart problem." 4. "My antacid will work best if I take it with my meals."

1. "I'll continue to take my antacid even if I feel better." Antacids decrease gastric acidity and should be continued even if the client's symptoms subside. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium.

The nurse should establish baseline data on a client who is starting on long-term gentamicin sulfate therapy. Which is least important for assessment screening in this client? 1. Visual acuity. 2. Vestibular function. 3. Renal function. 4. Auditory function.

1. Visual acuity. *LEAST IMPORTANT* Visual acuity is not affected by long-term gentamicin sulfate therapy. The nurse should establish baseline data for vestibular, renal, and auditory function because gentamicin sulfate is ototoxic and causes renal toxicity.

A nurse should expect to administer which vaccine to the client after a splenectomy? 1. hepatitis B vaccine 2. measles virus vaccine-live 3. pneumococcal vaccine-injection 4. tetanus toxoid

3. pneumococcal vaccine-injection Pneumococcal vaccine-injection, a polyvalent pneumococcal vaccine, is administered prophylactically to prevent the pneumococcal sepsis that sometimes occurs after splenectomy. Hepatitis B vaccine prevents hepatitis B. Measles virus vaccine-live is a live, attenuated virus vaccine for immunization against measles (rubeola). Tetanus toxoid is administered to prevent tetanus resulting from impaired skin integrity caused by traumatic injury.

A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. What should the nurse tell the client? 1. "There are no therapeutic benefits of ginseng." 2. "Taking ginseng will increase the risk of hypoglycemia." 3. "You can take the ginseng to help improve your memory." 4. "It's ok to take ginseng if you take it with a carbohydrate."

2. "Taking ginseng will increase the risk of hypoglycemia." Taking ginseng when on insulin is not encouraged because ginseng increases the risk of hypoglycemia. Ginseng can be therapeutic in certain situations but is potentially harmful to clients taking insulin. Taking ginseng with a carbohydrate will not offset the long acting effect of the ginseng.

During the evening shift on the day of a client's bowel resection surgery, the nasogastric (NG) tube drains 500 mL of green-brown fluid. The nurse should: 1. call the health care provider. 2. increase the IV infusion rate. 3. record the amount of drainage on the client's chart. 4. irrigate the tube with normal saline solution.

3. record the amount of drainage on the client's chart. Because peristalsis has not been reestablished, this amount of gastric drainage would be expected. The green-brown color would also be expected. The appropriate nursing action is to chart the amount and color of output and continue monitoring the client. There is no need to notify the health care provider or to provide additional IV fluids. A patent NG tube does not require irrigation.

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions? 1. "Walking around helps to decrease true contractions." 2. "True labor contractions may disappear with rest or sleep." 3. "The duration and frequency of true labor contractions remain the same." 4. "True labor contractions are felt first in the lower back, then the abdomen."

4. "True labor contractions are felt first in the lower back, then the abdomen." With true labor, the contractions are felt first in the lower back and then the abdomen. They gradually increase in frequency and duration and do not disappear with ambulation, rest, or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase true contractions. False labor contractions disappear with ambulation, rest, or sleep. False labor contractions commonly remain the same in duration and frequency. Clients who are experiencing false labor may have pain, even though the contractions are not very effective.

The nurse is preparing a client for paracentesis. What should the nurse do? 1. Have the client void before the procedure. 2. Scrub the client's abdomen with povidone-iodine solution. 3. Position the client supine. 4. Put the client on nothing-by-mouth (NPO) status 4 hours before the procedure.

1. Have the client void before the procedure. Before paracentesis, the client is asked to void. This is done to collapse the bladder and decrease the risk of accidental bladder perforation. The abdomen is not prepared with an antiseptic cleansing solution. The client is placed in a Fowler's position. The client does not need to be put on NPO status before the procedure.

A hospitalized 5-year-old is pulseless, and after verifying the child is not breathing, the nurse begins chest compressions. Where should the nurse apply pressure? 1. on the lower sternum with the heel of one hand 2. midway on the sternum with the tips of two fingers 3. over the apex of the heart with the heel of one hand 4. on the upper sternum with the heels of both hands

1. on the lower sternum with the heel of one hand The chest is compressed with the heel of one hand positioned on the lower sternum, two fingerbreadths above the sternal notch (at the nipple line). Fingertips are used to compress the sternum in infants. Heels of both hands are used in adult CPR.

A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker? 1. Contact 911. 2. Clamp the catheter. 3. Remove the catheter. 4. Position client on left side with head higher than the feet.

2. Clamp the catheter. The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. -The client should be positioned on the left side with head lower than the feet, not higher. -The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. -As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.

A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for? 1. confusion 2. muscle cramping 3. edema 4. tremors

2. muscle cramping Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.

A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by 1. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. 2. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. 3. draining urine from the drainage bag into a sterile container. 4. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

2. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there's no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? 1. straw-colored urine 2. reduced hematocrit 3. clay-colored stools 4. elevated urobilinogen in the urine

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

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? 1. a 20-year-old who is unresponsive and has a high injury to his spinal cord 2. an 80-year-old who has a compound fracture of the arm 3. a 10-year-old with a laceration on his leg 4. a 25-year-old with a sucking chest wound

4. a 25-year-old with a sucking chest wound During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

What finding indicates that a child is receiving too much IV fluid too rapidly? 1. marked increase in abdominal girth 2. evidence of protein in the urine 3. dark amber-colored urine 4. moist crackles in the lung fields

4. moist crackles in the lung fields Moist crackles in the lung fields are an indication that fluid is accumulating in the lungs due to overhydration or too rapid delivery of fluids. Abdominal girth would not provide information about the child's fluid status. Protein in the urine may be due to a disease process not fluid status. Dark amber-colored urine would be an indication of underhydration.

Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy? 1. partial thromboplastin time (PTT) 2. serum potassium 3. arterial blood gas (ABG) values 4. prothrombin time (PT)

4. prothrombin time (PT) Warfarin sodium interferes with clotting. The nurse should monitor the PT and evaluate for the therapeutic effects of coumadin. A therapeutic PT is between 1.5 and 2.5 times the control value; the PT should be established by the health care provider (HCP). It may also be reported as an International Normalized Ratio, a standardized system that provides a common basis for communicating and interpreting PT results. The PTT is monitored in clients who are receiving heparin therapy. Serum potassium levels and ABG values are not affected by coumadin.

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that the blood pressure is 96/60 mm Hg, with a heart rate of 120 bpm. The client just vomited coffee-ground-like material. Based on these data what should the nurse do first? a. Administer an antiemetic. b. Prepare to insert a nasogastric (NG) tube. c. Collect data regarding recent client stressors. d. Place the client in a modified Trendelenburg position.

b. Prepare to insert a nasogastric (NG) tube. The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status, and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting.

As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance? a. respiratory alkalosis b. metabolic alkalosis c. respiratory acidosis d. metabolic acidosis

c. respiratory acidosis As status asthmaticus worsens, the PaCO increases and the pH decreases, reflecting respiratory acidosis.

The nurse administers intravenous morphine to a client following surgery. Fifteen minutes later the client reports severe itching. What is the nurse's best action? 1. Administer diphenhydramine. 2. Administer naloxone. 3. Contact the healthcare provider. 4. Discontinue administration of morphine.

1. Administer diphenhydramine. Contraindications to the use of opioid analgesics include known drug allergy and severe asthma. Many clients will claim to be allergic to morphine because it causes itching. Itching is a pharmacologic effect due to histamine release and not an allergic reaction. Diphenhydramine can be administered for pruritus. It is not necessary to administer naloxone, contact the healthcare provider, or discontinue the morphine.

The nurse is reviewing laboratory values of a client receiving clozapine. Which laboratory value should the nurse report to the healthcare provider (HCP)? 1. WBC of 3,500/µL (3.5 X 109/L) 2. hemoglobin of 8.2 g/dL (82 g/L) 3. sodium level of 136 mEq/L (136 mmol/L) 4. hyaline casts in the urinalysis

1. WBC of 3,500/µL (3.5 X 109/L) A low WBC may indicate the development of agranulocytosis, a serious life threatening side-effect of clozapine, and should be reported immediately. While a hemoglobin of 8.2 mg/dL (8.2 g/L) is low, it is not life threatening. The sodium level of 136 mEq/L (136 mmol/L) is normal. Hyaline cast are usually caused by dehydration and indicate the need for more fluids.

A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is 1. renal calculi. 2. overdistended bladder. 3. interstitial cystitis. 4. acute prostatitis.

1. renal calculi. Renal calculi usually present as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor. The client with an overdistended bladder and interstitial cystitis presents with dull, continuous pain at the suprapubic area that's intense with voiding. The client also complains of urinary urgency and straining to void. The client with acute prostatitis presents with a feeling of fullness in the perineum and vague back pain, along with frequency, urgency, and dysuria.

The nurse is assessing a client for heroin addiction. Which finding indicates the client has used heroin? 1. sclera red and bloodshot 2. pupils small and constricted 3. pupils large and dilated 4. drooping eyelids

2. pupils small and constricted -Heroin causes pinpoint pupils. -Marijuana causes the eyes to appear red and bloodshot. -Cocaine use causes pupils to dilate. -Drooping of the eyelids is not typically associated with the use of any substance.

Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data? 1. The client is developing an infection of the urinary tract. 2. The mucus is caused by elevated levels of glucose in the urine. 3. These findings are normal for a client with an ileal conduit. 4. There is irritation of the stoma.

3. These findings are normal for a client with an ileal conduit. A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection or stomal irritation. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine.

When performing a scrotal examination, a nurse finds a nodule. What should the nurse do next? 1. Notify the physician. 2. Change the client's position and repeat the examination. 3. Perform a rectal examination. 4. Transilluminate the scrotum.

4. Transilluminate the scrotum. The nurse who discovers a nodule, swelling, or other abnormal finding during a scrotal examination should transilluminate the scrotum by darkening the room and shining a flashlight through the scrotum behind the mass. A scrotum filled with serous fluid transilluminates as a red glow; a more solid lesion, such as a hematoma or mass, doesn't transilluminate and may appear as a dark shadow. Although the nurse should notify the physician of the abnormal finding, performing transillumination first provides the physician with additional information. The nurse can't uncover more information about a scrotal mass by changing the client's position and repeating the examination or by performing a rectal examination.

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should a. elevate the client's head to 90 degrees. b. press the right upper abdomen. c. press the left upper abdomen. d. lay the client flat in bed.

b. press the right upper abdomen. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.

A client has been receiving oxytocin to augment her labor. The nurse notes that contractions are lasting 100 seconds. Which immediate action should the nurse take? 1. Stop the oxytocin infusion. 2. Notify the provider. 3. Monitor fetal heart tones as usual. 4. Turn the client on her left side.

1. Stop the oxytocin infusion. Oxytocin should be withheld immediately, as it stimulates contractions. A contraction that continues for more than 90 seconds signals tetany and could lead to decreased placental perfusion and possibly uterine rupture. The nurse should monitor the fetal heart tones, stop the oxytocin, and notify the provider. The client should be turned on her left side to increase blood flow to the fetus, which can be decreased with tetany. This decreased blood flow can potentially compromise the fetus.

The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem? 1. Readjust the solution to infuse the desired amount. 2. Continue the infusion at the current rate, but run the next bottle at an increased rate. 3. Double the infusion rate for 2 hours. 4. Notify the health care provider (HCP).

4. Notify the health care provider (HCP). When TPN fluids are infused too rapidly or too slowly, the HCP should be notified. TPN solutions must be carefully and accurately infused. Rate adjustments should not be made without a written prescription from the HCP. Significant alterations in rate (10% increase or decrease) can result in fluctuations of blood glucose levels. Speeding up the solution can result in too much glucose entering the system.

The nurse is providing information to a client who is taking chlorpromazine. What is the most important information for the nurse to provide? 1. Reduce the dosage if feeling better. 2. Stop taking medication when sunbathing. 3. Stop taking the drug if adverse reactions develop. 4. Schedule routine medication checks.

4. Schedule routine medication checks. Chlorpromazine = ANTIPSYCHOTIC (1st gen) It is important to continually assess for adverse reactions and continued therapeutic effectiveness. The dosage should be changed if ordered by the primary care provider. While chlorpromazine can exacerbate serious sunburns, medication should not be discontinued without an order from the provider. Adverse reactions should be immediately reported to the provider.

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? 1. collecting semen 2. performing the pelvic examination 3. obtaining consent for examination 4. supporting the client's emotional status

4. supporting the client's emotional status The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

Which information should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) following treatment with intravenous immunoglobulin (IVIG)? a. Offer the child extra fluids every 2 hours for 2 weeks. b. Take the child's temperature daily for several days. c. Check the child's blood pressure daily until the follow-up appointment. d. Call the health care provider (HCP) if the irritability lasts for 2 more weeks.

b. Take the child's temperature daily for several days. The child's temperature should be taken daily for several days after discharge because children who develop a fever may require a second IVIG treatment. Offering the child fluids every 2 hours is not necessary. Doing so increases the child's risk for CHF. Checking the child's blood pressure at home usually is not included as part of the discharge instructions because by the time of discharge the child is considered stable and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may last for 2 months after discharge.

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base their response on the fact that the a. area of redness is measured in 3 days and determines whether tuberculosis is present. b. skin test doesn't differentiate between active and dormant tuberculosis infection. c. presence of a wheal at the injection site in 2 days indicates active tuberculosis. d. test stimulates a reddened response in some clients and requires a second test in 3 months.

b. skin test doesn't differentiate between active and dormant tuberculosis infection. The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. Which symptom should the nurse teach the client to report? 1. sore throat 2. excessive menstruation 3. constipation 4. increased urine output

1. sore throat The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider (HCP) signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.