Adaptive Quizing

A 7-year-old child was recently found to have juvenile idiopathic arthritis. The parents are concerned about the lifelong effects of the disorder and are investigating other therapies to use with the medications. What referral should the nurse recommend? 1. Physical therapy 2. Special education 3. Nutritional therapy 4. Herbal supplements

1. Physical therapy A physical therapist can prescribe an exercise protocol to keep the joints as mobile as possible; a routine can be developed to help the child alleviate morning stiffness. Special education might be necessary in the future; there is no evidence that it is needed at this time. Although nutrition is an appropriate part of therapy, it is the physical therapy program that can most directly influence movement. Over-the-counter medications should not be used without the supervision of a healthcare provider.

The nurse instructs a client about the safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which action of the client does the nurse expect is the reason for the client's condition? Select all that apply. 1. Massaging the reddened skin areas 2. Placing pillows between two bony surfaces 3. Using donut-shaped pillows for pressure relief 4. Keeping the head of the bed below 30 degrees 5. Using a bed pillow under the ankles to keep the heels off the bed surface

1. Massaging the reddened skin areas 3. Using donut-shaped pillows for pressure relief The client with a pressure ulcer should gently pat the skin rather than massaging the reddened skin areas, which results in dryness. Using donut shaped pillows may aggravate the client's condition. Placing pillows or foam wedges between two bony surfaces during positioning may provide comfort to the client. The client should avoid maintaining the head of the bed elevated above 30 degrees to prevent shearing. Keeping the client's heels off the bed surface using a bed pillow under the ankles ensures safety in the client.

The nurse must understand the process of changing behaviors to be able to support difficult behavioral changes in clients. Arrange the Stages of Health Behavior Change as described by DiClemente and Prochaska (1998) in the transtheoretical model of change. 1. Action 2. Preparation 3. Contemplation 4. Maintenance stage 5. Precontemplation

Precontemplation contemplation preparation action maintenance stage The first stage of behavioral change is the precontemplation stage. During this stage, the client may be defensive when confronted with information about the behavior. The client does not intend to make any changes within the next six months. The second stage is the contemplation stage. The client begins to consider a change within the next six months as he or she develops more belief in the value of change. The third stage is preparation when the client believes that advantages outweigh disadvantages of behavior change. The client needs assistance planning for a change in the next month. The fourth stage is action, which will last up to six months. During this stage the client is actively engaged in strategies to change behavior while the nurse identifies barriers to change. The fifth stage is the maintenance stage, which begins six months after the change has started and continues indefinitely.

An obese client must self-administer insulin at home. The nurse will teach the client to inject insulin at which angle? 1. 30-degree angle 2. 60-degree angle 3. 45-degree angle 4. 90-degree angle

4. 90-degree angle Injection should be made at a 90-degree angle for most patients, including those of normal weight. Injecting at a 30-degree angle or a 60-degree angle is not appropriate for the obese, normal weight, the child, or the thin client. If injecting into a child or a thin client, the injection should be made at a 45-degree angle.

A 10-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage? 1. Baked potato, meatloaf, banana, and pretzels 2. Baked ham, bread and butter, peaches, and milk 3. Corn on the cob, baked chicken, rice, apple, and milk 4. Hot dog on a bun, potato chips, dill pickle slices, and brownie

3. Corn on the cob, baked chicken, rice, apple, and milk Corn, chicken, rice, apples, and milk are permitted on the low-sodium, low-potassium diet that the child should be following. Bananas and potatoes are high in potassium, and pretzels are high in sodium. Only the peaches are low in sodium, and all but the butter are fairly high in potassium. Processed foods are high in sodium and fairly high in potassium.

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1 Lips 2 Sclera 3 Conjunctiva 4 Mucus membrane

1 Lips The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.

Which assessment finding of the skin refers to elasticity? 1 Turgor 2 Edema 3 Texture 4 Vascularity

1 Turgor Turgor refers to the elasticity of the skin. Edema indicates fluid buildup in the tissues. Texture refers to the character of the skin. Vascularity refers to the circulation of the skin.

The nurse is caring for four clients. Which client should the nurse care for first? a. Pt with cardiomyopathy with lower extremities swollen and weight gain b. Pt with PAD with painful cramping in hip region, with weakness and numbness in leg c. Pt with aortic aneurysm with difficulty breathing and chest pain d. Pt with chest trauma with difficulty breathing and hemoptysis

d. Pt with chest trauma with difficulty breathing and hemoptysis Client D with chest trauma who is coughing up blood and experiencing difficulty breathing should be cared for first. Client A with cardiomyopathy and swelling of the lower extremities and weight gain can be treated later as the client can wait for treatment. Client B with peripheral artery disease can be treated after treating the clients with emergency conditions as this client can wait for treatment. Client C with an aortic aneurysm and chest pain with difficulty breathing can be cared for after client D because there is no sign that the aneurysm has ruptured

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? 1 Hypoventilation 2 Biot's respiration 3 Kussmaul's respiration 4 Cheyne-Stokes respiration

3 Kussmaul's respiration Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? 1. Picks up the walker and carries it for short distances 2. Uses the walker only when someone else is present 3. Moves the walker no more than 12 inches (30.5 cm) in front of the client during use 4. States that a walker will be purchased on the way home from the hospital

3. Moves the walker no more than 12 inches (30.5 cm) in front of the client during use Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

The nurse is providing treatment to a client for the leakage of a vesicant intravenous solution into the extravascular tissue via the short peripheral catheter. What is the most important nursing priority after the nurse has stopped the infusion and disconnected administration set? 1. The nurse should photograph the site. 2. The nurse should administer the antidote. 3. The nurse should aspirate the drug from a short peripheral catheter. 4. The nurse should apply cold compresses for all drugs except vinca alkaloids and epipodophyllotoxins.

3. The nurse should aspirate the drug from a short peripheral catheter. The most important step after the nurse has stopped the infusion and disconnected the administration set is to aspirate the drug from the short peripheral catheter. The nurse should photograph the site after applying cold compress. The next most important step after the stopping the infusion process is the administration of the antidote. After the administration of the antidote, apply a cold compress. The nurse should use a cold compress for all drugs except vinca alkaloids and epipodophyllotoxins.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? 1. Fever and chest pain 2. Positive Homans sign 3. Loss of sensation in the operative leg 4. Tachycardia and petechiae over the chest

4. Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.

A client who has just started on a regimen of haloperidol is observed pacing and shifting weight from one foot to the other. What side effect does the nurse document in the client's chart? 1. Akathisia 2. Parkinsonism 3. Tardive dyskinesia 4. Acute dystonic reaction

1. Akathisia Restlessness or the desire to keep moving (akathisia) can occur within 6 hours of the first dose of haloperidol; this side effect is associated with most neuroleptics. Parkinsonian side effects include masklike facies, tremors, and shuffling gait. Tardive dyskinesia is a severe, largely irreversible, extrapyramidal side effect occurring after prolonged treatment with phenothiazines. Acute dystonic reaction is characterized by severe, bizarre muscle contractions.

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client? 1 Apnea 2 Bradypnea 3 Tachypnea 4 Hyperpnea

2 Bradypnea In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

The x-ray report of a client shows the presence of a greenstick fracture. What is a greenstick fracture? 1. A fracture with more than two fragments 2. An incomplete fracture with one side bent 3. A spontaneous fracture at the site of bone disease 4. A fracture that extends across the longitudinal axis of the bone shaft

2. An incomplete fracture with one side bent An incomplete fracture with one side splintered and the other side bent indicates a greenstick fracture. A fracture with more than two fragments that appear to be floating is known as a comminuted fracture. A pathological fracture is a spontaneous fracture found at the site of bone disease. A transverse fracture extends across the longitudinal axis of the bone shaft.

Which site is best used to inspect a client who is suspected to have jaundice? 1 Skin 2 Palm 3 Sclera 4 Conjunctiva

3 Sclera The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended. The palms and conjunctiva are inspected to assess pallor.

A registered nurse is evaluating the actions of a nursing student who is injecting an allergen in a client having a severe anaphylactic reaction to insect venom. Which action of the nursing student requires correction? 1. Rotating the sites for each injection 2. Aspirating for blood before giving the injection 3. Injecting in an extremity close to a joint 4. Observing the client for 20 minutes after an injection

3. Injecting in an extremity close to a joint The allergen extract should always be administered in an extremity away from a joint so that a tourniquet can be applied for a severe reaction. The injection sites should be rotated for each injection to prevent skin damage. Aspirating for blood before giving an injection should always be done to ensure that the allergen extract is not injected into a blood vessel. Systemic reactions are likely to occur immediately. Therefore the client should be observed for 20 minutes after the injection.

An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 1 36.0ºC 2 36.8ºC 3 37.2ºC 4 38.5ºC

4 38.5ºC In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.

A nurse is assessing an infant for developmental dysplasia of the hip. How does the nurse identify the Ortolani sign? 1. Unilateral droop of the hip 2. Broadening of the perineum 3. Apparent shortening of one leg 4. Audible click on hip manipulation

4. Audible click on hip manipulation With specific manipulation an audible click may be heard as the femoral head slips into the acetabulum; this is known as the Ortolani sign. Unilateral droop of the hip is the Trendelenburg sign; it is associated with weight bearing. Broadening of the perineum is associated with bilateral dislocation. Apparent shortening of one leg is the Allis sign.

The primary healthcare provider prescribed antitubercular medications to four clients with tuberculosis. Which client is at risk for hyperuricemia? Client A = Pyrazinamide Client B = Isoniazid Client C = Ethambutol Client D = Rifampin

Client A = Pyrazinamide Pyrazinamide is an antitubercular medication that causes hyperuricemia. Client A is at risk for hyperuricemia. Client B, who is prescribed isoniazid, is at risk for hepatitis. Client C, who is prescribed ethambutol, is at risk for ocular toxicity. Client D, who is prescribed rifampin, is at risk for thrombocytopenia.

A 6-year-old child with a body surface area (BSA) of 0.36 m2 has been prescribed amoxicillin. The adult dose of amoxicillin is 500 mg. Calculate the dose for the child. Record your answer using a whole number. __________ mg

Therefore the child dose is 0.36 m2 × 500 mg/m2 = 180 mg.

Which type of bone tumor is commonly seen in elderly clients? 1. Endochroma 2. Osteosarcoma 3. Chondrosarcoma 4. Osteochondroma

3. Chondrosarcoma Chondrosarcoma occurs most commonly in cartilage in the arm, leg, and pelvic bones of older adults in the age group of 50 to 70 years old. Endochroma occurs in clients in the age group of 10 to 20 years old. Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years old.

A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1. Blood glucose is 70-100 mg/dL 2. An increased serum lactate level 3. An increased neutrophil level 4. A white blood count of 5000 cells/µL

2. An increased serum lactate level The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count > 12,000 cells/µL or < 4,000 cells/µL and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL. Blood glucose levels of 70-100 mg/dL are considered normal.

Which hormone overproduction is associated with carpel tunnel syndrome in clients? 1. Growth hormone 2. Antidiuretic hormone 3. Parathyroid hormone 4. Aldosterone hormone

1. Growth hormone Overproduction of growth hormone is associated with carpel tunnel syndrome. Overproduction of aldosterone hormone is associated with Conn's syndrome. Antidiuretic hormone overproduction can result in syndrome of inappropriate antidiuretic hormone. Overproduction of parathyroid hormone results in hyperparathyroidism.

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1 Low purine 2 Low calcium 3 High phosphorus 4 High alkaline ash

2 Low calcium A low calcium intake is recommended. Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? 1 Frothy stools 2 Weak, rapid pulse 3 Pale, copious urine 4 Bulging anterior fontanel

2 Weak, rapid pulse A weak, rapid pulse is an expected adaptation with a state of severe dehydration because of hypovolemia. Children with untreated cystic fibrosis and celiac disease have frothy stools. There is no indication that this infant has either of these disorders. Severe dehydration results in decreased urine output and concentrated urine. One of the signs of dehydration in an infant is a sunken, not bulging, anterior fontanel.

What is the sequence of techniques used while assessing the abdomen? 1. Palpation 2. Inspection 3. Auscultation 4. Percussion

2. Inspection 3. Auscultation 4. Percussion 1. Palpation The order of an abdominal assessment begins with inspection of the contour, symmetry, and surface motion of the abdomen. The nurse will note any masses, bulging, or distention. The second step is auscultation, which is done before palpation to reduce the chance of altering the frequency and character of bowel sounds. The third step is percussion, which is used to assess kidney inflammation. The fourth step is palpation, which detects areas of abdominal tenderness, distention, or masses.

Which assessment is expected when a client is placed in the lithotomy position during physical examination? 1 Assessment of the heart 2 Assessment of the rectum 3 Assessment of the female genitalia 4 Assessment of the musculoskeletal system

3 Assessment of the female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client? 1 Eye tumors 2 Hypothyroidism 3 Hyperthyroidism 4 Neuromuscular injury

3 Hyperthyroidism Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? 1 Neurologic 2 Wound 3 Pain 4 Skin

3 Pain Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurologic check is not necessary unless the client's neurologic status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect? 1 Eczema 2 Hypersensitivity 3 Contact dermatitis 4 Anaphylactic shock

3. Contact dermatitis A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

Which positioning should be avoided while assessing a client with a history of asthma? 1 Sitting 2 Supine 3 Dorsal recumbent 4 Lateral recumbent

4 Lateral recumbent The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.

Which joint permits movement in any direction? 1. Pivot joint 2. Hinge joint 3. Biaxial joint 4. Ball-and-socket joint

4. Ball-and-socket joint Ball-and-socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement.

A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1. Refer the client to the primary healthcare provider only if other neurologic deficits are present. 2. Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. 3. Stress the importance of having the client call the primary healthcare provider as soon as possible. 4. Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.

4. Make arrangements immediately for further medical evaluation by the client's primary healthcare provider. Numbness, a sensory deficit, is inconsistent with parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending brain attack (cerebrovascular accident, CVA). This symptom is not caused by parkinsonism; increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary healthcare provider as soon as possible can cause a delay in the client's receiving immediate medical attention.

Which statement is true about the diet plan for toddlers? 1. Refrain from serving finger foods. 2. Toddlers need 4 to 6 cups of milk per day. 3. Low-fat or skimmed milk should be given until the child is 2 years old. 4. Milk should be supplemented with solid food items like vegetables and fruits.

4. Milk should be supplemented with solid food items like vegetables and fruits. In toddlers, the parents should be supplementing the child's intake of milk with solid foods items, ensuring a balanced diet for adequate growth. Serving finger foods to toddlers allows them to eat by themselves and to satisfy their need for independence and control. The intake of milk should be limited to 2 to 3 cups because the consumption of more than a quart of milk per day tends to decrease the child's appetite for essential solid foods and results in inadequate iron intake. Children below 2 years of age should not be given low-fat or skimmed milk because the fat is important for the physical and intellectual growth of the child.

The nurse is applying capsaicin to a client with diabetic neuropathy. Which action should the nurse perform immediately after applying the medication? 1. Monitor for skin irritation. 2. Perform a painful procedure. 3. Notify the healthcare provider. 4. Remove gloves and wash hands.

4. Remove gloves and wash hands. Topical applications of local anesthetics such as capsaicin are used to interrupt transmission of pain signals to the brain in a client with diabetic neuropathy. The nurse has to use gloves or wash the hands with soap and water after application of capsaicin to prevent nerve blockage in the nurse. The client should be monitored for skin irritation at the site of application. Painful procedures are performed only when the client loses pain perception at the site. The healthcare provider is notified if the client has severe side effects.

A client residing in an assisted living facility is diagnosed with Parkinson disease, and the healthcare provider prescribes selegiline. What precaution will the nurse teach the client? 1. Change to a standing position slowly. 2. Take the medication between meals. 3. Perform self-blood glucose monitoring. 4. Withhold the next dose if nausea occurs.

1. Change to a standing position slowly. A common side effect of selegiline is dizziness. Safety precautions are necessary to prevent falls caused by orthostatic hypotension. Taking the medication with food or milk limits gastrointestinal irritation. Monitoring blood glucose levels is not necessary. Nausea is a common side effect of selegiline; the medication should not be withheld without the healthcare provider's supervision. Abrupt withdrawal may precipitate a parkinsonian crisis.

A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing which ingredient? 1. Sodium 2. Calcium 3. Aluminum 4. Magnesium

1. Sodium If the client consumes more than the usual daily sodium intake, excess fluid retention results; this will increase the cardiac workload. Antacids that do not contain sodium do not cause fluid retention; however, it is best for this client to seek medical advice before taking an antacid.

A pregnant client is admitted to the high-risk unit with abdominal pain and heavy vaginal bleeding. What is the nurse's priority intervention? 1. Starting oxygen therapy 2. Administering an opioid 3. Elevating the head of the bed 4. Drawing blood for laboratory tests

1. Starting oxygen therapy The client is hemorrhaging and has decreased cardiac output. Oxygen is necessary to prevent further maternal and fetal compromise. Administering an opioid will sedate an already compromised fetus. Elevating the head of the bed will decrease blood flow to vital centers in the brain. Although blood should eventually be drawn for laboratory tests, it is not the priority.

A healthcare provider's prescription for a client in ketoacidosis is 60 units of insulin IV in the next 30 minutes. The pharmacy dispensed 500 units regular insulin in 500 mL lactated Ringer solution. At how many milliliters per hour should the nurse set the IV infusion device to administer the correct amount of medication? Record your answer using a whole number. _____ mL/hr.

120mL/hr The prescribed amount of insulin is 60 units. The total time of infusion is 30 minutes. The available concentration is 500 units/500 mL. Use dimensional analysis to determine the appropriate rate in mL/hr.

A client who is being treated for pruritus complains of sedation. Which medication does the nurse anticipate being prescribed by the primary healthcare provider to treat this side effect? 1. Loratadine 2. Hydroxyzine 3. Diphenhydramine 4. Triamcinolone acetonide

1. Loratadine Loratadine is a non-sedative drug used in treating sedation caused by antihistamine drugs. Hydroxyzine and diphenhydramine are antihistamine drugs used in the treatment of pruritus; sedation is a side effect of these drugs. Triamcinolone acetonide is an intralesional corticosteroid used in the treatment of psoriasis.

A pregnant client asks the nurse for information regarding toxoplasmosis exposure during pregnancy. What information should the nurse teach this client? 1. "Pork and beef should be cooked thoroughly." 2. "Toxoplasmosis is a disease that is most prevalent in foreign countries." 3. "Raw shellfish are intermediary hosts and should be avoided during pregnancy." 4. "Salad dressings made with mayonnaise should be avoided during the summer months."

1. "Pork and beef should be cooked thoroughly." Thorough cooking of pork and beef before consumption helps prevent ingestion of the cyst stage of the Toxoplasma protozoa. Even though toxoplasmosis is more prevalent in foreign countries, it occurs in the United States and its prevention should be addressed. Raw shellfish are not related to toxoplasmosis. Salad dressings made with mayonnaise are not linked to toxoplasmosis.

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? 1. Lactase 2. Sucrase 3. Maltase 4. Amylase

1. Lactase Milk and milk products are not tolerated well because they contain lactose, a sugar that is converted to galactose by lactase. Sucrase assists in the digestion of sucrose, which is not a milk sugar. Maltase assists in the digestion of maltose, which is not a milk sugar. Amylase assists in the digestion of starch, which is not a milk sugar.

Which nursing theory focuses on the client's self-care needs? 1 Roy's theory 2 Orem's theory 3 Watson's theory 4 Leininger's theory

2 Orem's theory Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? 1. Weight gain 2. Dehydration 3. Hyperactivity 4. Hyperglycemia

2. Dehydration The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.

A 6-year-old child treated for acute glomerulonephritis has improved and is soon to be discharged. What should the nurse plan to offer the parents in preparation for the discharge? 1. Samples of no-salt-added diets for the child to continue at home 2. Suggestions about activities to keep the child mobile for longer periods 3. Instructions about when the child should return for a workup for a kidney transplant 4. Phone numbers to reach the nurse on the unit so the parents may call if there are any questions

1. Samples of no-salt-added diets for the child to continue at home Foods high in sodium and salty treats are usually limited to control or prevent edema and hypertension until the child is asymptomatic. The child should not be kept active for long periods because rest is needed; the child usually does not need a long convalescence. Glomerulonephritis usually does not cause such severe kidney damage that a kidney transplant is necessary. The mother should contact the healthcare provider, not the nurse on the unit, for follow-up care.

Client A: Presence of uric acid crystals in the fluid Client B: floating fat globules in the fluid Client C: thick, purulent fluid Client D: Transparent, straw-colored fluid The nurse is reviewing the joint fluid examination reports of four clients. Which client's report indicates a normal finding? 1. Client A 2. Client B 3. Client C 4. Client D

4. Client D Joint fluid is normally transparent and colorless or straw-colored. Therefore client D's joint fluid is normal. The presence of uric acid crystals in client A's fluid suggests gout. Floating fat globules in client B's joint fluid indicate a bone injury. The thick, purulent joint fluid found in client C indicates infection.

A 30-week-pregnant woman reports low backache and abdominal cramps. Which drug may be prescribed if the client is suspected of having preterm labor? 1. Methylergonovine 2. Mifepristone 3. Calcium gluconate 4. Magnesium sulfate

4. Magnesium sulfate Low backache and abdominal cramps in a pregnant woman may indicate labor; however, labor pains may not be safe if the gestation is not at full term. Magnesium sulfate may be prescribed to prevent preterm labor. Methylergonovine is prescribed to reduce postpartum uterine hemorrhage. Mifepristone may cause an elective termination of pregnancy. Calcium gluconate may be prescribed to reverse magnesium toxicity.

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply. 1. Limiting contact with the abuser 2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number 4. Obtaining a bank loan to finance leaving the abuser 5. Arranging for a family member to assist her in leaving

2. Determining a safe place to go in an emergency 3. Memorizing the domestic violence hotline number It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do? 1. Ask the nursing supervisor to discuss this with the healthcare provider. 2. Encourage the family to bring in special foods preferred in their culture. 3. Order a high-protein milkshake as a between-meal snack to stimulate her appetite. 4. Explain to the family that the dietitian plans nutritious meals that the client should eat.

2. Encourage the family to bring in special foods preferred in their culture. In family-centered childbearing, care should be adapted to the client's cultural system whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility. Ordering a high-protein milkshake as a between-meal snack to stimulate appetite may be useful, but the primary intervention is addressing the client's cultural needs. Explaining to the family that the dietitian plans nutritious meals that the client should eat does not address the underlying problem.

On reviewing the medical history, the nurse finds that the client is prescribed mycophenolate mofetil for late graft loss. Which other medications could also be co-administered? Select all that apply. 1. Tacrolimus 2. Cyclosporine 3. Acetaminophen 4. Diphenhydramine 5. Methylprednisolone

1. Tacrolimus 2. Cyclosporine Mycophenolate is a lymphocyte-specific inhibitor of purine synthesis with suppressive effects on both T and B lymphocytes. Tacrolimus and cyclosporine are co-administered with mycophenolate as it shows additive effect because it acts later in the lymphocyte activation pathway by a different mechanism, reducing late graft loss. Acetaminophen, diphenhydramine, and methylprednisolone are administered to reduce the expected adverse effects such as headache, myalgia, and various gastrointestinal disturbances that occur with monoclonal antibodies such as muromonab-CD3.

A client who has schizophrenia is receiving a phenothiazine antipsychotic medication. Which serious client responses to the medication will the nurse immediately report to the primary healthcare provider? Select all that apply. 1. Akathisia 2. Shuffling gait 3. Yellow sclerae 4. Photosensitivity 5. Involuntary tongue movements

3. Yellow sclerae 5. Involuntary tongue movements Yellow sclerae are a sign of toxicity that has damaged the liver and necessitates withholding the drug. Abnormal movements of involuntary muscle groups, particularly of the face, mouth, tongue, fingers, and toes, can occur after a prolonged period of dopamine blockade. Conversion to an atypical antipsychotic is warranted. Akathisia and a shuffling gait are common side effects that usually are alleviated by antiparkinsonian agents. Photosensitivity is an expected side effect of the drug; the medication does not have to be withheld.

The school nurse is attending to a student athlete who reports muscle pain after a practice session. Which should the nurse identify as a cause of this pain when providing instruction to the student? 1. Lactic acid 2. Acetoacetic acid 3. Hydrochloric acid 4. Beta-hydroxybutyric acid

1. Lactic acid The ache in muscles that have been vigorously worked without adequate oxygen supply is caused in part by the buildup of lactic acid. During rest, the lactic acid is oxidized completely to carbon dioxide and water, providing adenosine triphosphate (ATP) for further muscular contraction. Beta-hydroxybutyric acid and acetoacetic acid are not products of muscle contraction; they are ketone bodies resulting from incomplete oxidation of fatty acids. Hydrochloric acid is not a product of muscle contraction; it is present in the stomach to facilitate the digestive process.

Calculate the dose of acetaminophen for a 3-year-old child with the body surface area of 0.30 m2. The adult dose of the drug is 500 mg. Record your answer using a whole number. _____mg

Using the body surface area formula, the child's dose can be calculated as follows: Child's dose = (BSA of child/m2) * adult dose 150 mg = (0.30 m2/m2) * 500 mg Therefore the child should be administered 150 mg of the medication.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time? 1 Addressing the pain 2 Reversing feelings of hopelessness 3 Promoting mobility in the residual limb 4 Acknowledging the grieving for the lost limb

1 Addressing the pain Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress? 1 Bland foods 2 Regular diet 3 Gluten-free foods 4 Low-carbohydrate foods

1 Bland foods A bland, nonirritating diet is recommended during the acute symptomatic phase. During the acute phase, a regular diet can cause discomfort. Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Select all that apply. 1 Fainting 2 Headache 3 Weakness 4 Lightheadedness 5 Shortness of breath

1 Fainting 3 Weakness 4 Lightheadedness Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.

A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1 Left Sims 2 Back lying 3 Knee chest 4 Mid-Fowler

1 Left Sims To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

1 Planning The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? 1 Use lemon juice to season meat. 2 Put condiments on food to add flavor. 3 Include canned vegetables in meal preparation. 4 Drink carbonated beverages instead of decaffeinated coffee.

1 Use lemon juice to season meat. Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.

A client who is undergoing treatment for osteomyelitis reports bloody, watery diarrhea. The client also has hives and mouth sores. Which medication will the nurse check for in the client's medication administration record? 1. Cefazolin 2. Neomycin 3. Tobramycin 4. Ciprofloxacin

1. Cefazolin Cephalosporin antibiotics, such as cefazolin, are used to treat osteomyelitis. Cefazolin can alter gastrointestinal function, resulting in adverse effects such as watery diarrhea, bloody stools, and mouth or throat sores. Cefazolin can also alter skin integrity and cause hives. Aminoglycoside antibiotics such as neomycin and tobramycin do not generally alter the gastrointestinal system; instead, they can cause ototoxicity and nephrotoxicity. Fluoroquinolones such as ciprofloxacin generally do not alter the gastrointestinal system and therefore do not cause watery, bloody stools. However, tendon rupture, especially of the Achilles tendon, can occur with the use of fluoroquinolones.

The primary healthcare provider suspects agranulocytosis in a client with a history of bipolar disorder (BPD). Which drug used to treat BPD is responsible for this condition? 1. Clozapine 2. Olanzapine 3. Risperidone 4. Aripiprazole

1. Clozapine Atypical antipsychotics are generally used to treat clients with bipolar disorder (BPD) to control symptoms during mania and to stabilize mood. Although clozapine is highly effective in treating BPD, this drug is not preferred because it may cause agranulocytosis. Olanzapine is approved for long-term use to prevent the recurrence of mood episodes. Side effects of this drug include weight gain, diabetes, and dyslipidemia. Risperidone along with mood stabilizers such as antiepileptic drugs are used to treat BPD; this drug's side effects include dizziness, somnolence, and fatigue. Aripiprazole is an approved drug for long-term use in clients with BPD. The side effects of aripiprazole include agitation, nervousness, anxiety, and insomnia.

Which musculoskeletal system change is associated in older adult clients? 1. Decreased in height 2. Decreased neck rigidity 3. Increased fine-motor dexterity 4. Increased range of motion (ROM)

1. Decreased in height Loss of height and deformity and shortening of the trunk are common in older adults due to vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increases with age due to loss of elasticity in ligaments, tendons, and cartilage. A decline in fine-motor dexterity occurs in the older adult due to slow impulse conduction along motor units. Range of motion (ROM) is limited in the older adult due to cartilage erosion, increased friction between the bones, and overgrowth of bone around joint margins.

An older adult, who alternately lives in a homeless shelter and on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and prescribes a purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed. 1. Institute airborne precautions. 2. Notify the Department of Health. 3. Obtain a sputum specimen. 4. Have a chest x-ray performed. 5. Perform a PPD intradermal skin test

1. Institute airborne precautions. 4. Have a chest x-ray performed. 5. Perform a PPD intradermal skin test 3. Obtain a sputum specimen. 2. Notify the Department of Health. Tuberculosis is transmitted via microorganisms that travel with air currents. The client should be placed in a room that has at least six exchanges of air per hour and is ventilated to the outside. Caregivers should wear a high-efficiency particulate air respirator. A chest x-ray study is the quickest way to determine the presence of suspicious lesions in the lung. A PPD test can be read in 48 to 72 hours. A positive culture may not develop for 3 to 6 weeks. The Department of Health (Canada: Public Health Agency) should be notified when the diagnosis of tuberculosis is confirmed.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? 1 Milk 2 Tea 3 Orange juice 4 Tomato juice

2 Tea The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history? 1. Any rectal cancer in the family 2. All foods eaten in the past 24 hours 3. Any recent extreme emotional stress 4. An upper respiratory infection in the past 10 days

2. All foods eaten in the past 24 hours The salmonella organism thrives in warm, moist environments; all foods eaten within the last 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

A client has surgery for an incarcerated hernia. The healthcare provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions? 1. Reduce dietary roughage. 2. Avoid lifting heavy items. 3. Increase dietary potassium intake. 4. Keep the head of the bed elevated

2. Avoid lifting heavy items. Avoiding lifting helps prevent increased intraabdominal pressure that may disrupt the surgical repair. Roughage helps prevent constipation, thus avoiding straining and increased intraabdominal pressure. There is no indication for potassium supplements. The client can assume any position of comfort.

Which structure protects a client's internal organs, supports blood cell production, and stores minerals? 1. Joints 2. Bones 3. Muscles 4. Cartilages

2. Bones Bones are the framework of the body; they support and protect internal organs. They also help in stem cell production from bone marrow, and they store minerals. Joints (articulations) help to articulate the bones. Muscles are the bundles of fibrous tissue that contract to produce movement and maintain body posture. Cartilage is a hyaline, elastic, and fibrous tissue that often functions as a shock absorber.

A client asks the nurse what advantage breast-feeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? 1. Amino acids 2. Gamma globulins 3. Essential electrolytes 4. Complex carbohydrates

2. Gamma globulins The antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? 1. Reduce gastric acidity 2. Reduce colonic irritation 3. Reduce intestinal absorption 4. Reduce bowel infection rate

2. Reduce colonic irritation A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.

A client on medication for transplant rejection is admitted with hypertension, nephrotoxicity, and gingival hyperplasia. Which medication might have caused this? Select all that apply. 1 . Sirolimus 2. Tacrolimus 3. Basiliximab 4. Cyclosporine 5. Mycophenolate

2. Tacrolimus 4. Cyclosporine Tacrolimus and cyclosporine are calcineurin inhibitors that may cause adverse effects such as hypertension, nephrotoxicity, and gingival hyperplasia. These drugs are administered to stop the production and secretion of interleukin, which then prevents the activation of lymphocytes involved in transplant rejection. Basiliximab targets the activation sites of T-lymphocytes, increasing their elimination from circulation. Sirolimus is an antiproliferative medication that may cause adverse immunosuppressive effects such as thrombocytopenia and leucopenia. Basiliximab is a monoclonal antibody that may cause adverse side effects related to the gastrointestinal system. Mycophenolate may cause adverse effects such as leukopenia, thrombocytopenia, and nausea.

A client in active labor starts screaming, "The baby is coming! Do something!" What is the nurse's primary action? 1 Notifying the practitioner of the imminent birth 2 Telling the client that it is too soon and encouraging her to pant 3 Checking the perineal area for the presenting part 4 Helping the client hold her knees together and explaining what to expect

3 Checking the perineal area for the presenting part The primary action by the nurse should be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse should remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? 1 Palpation 2 Inspection 3 Percussion 4 Auscultation

3 Percussion Percussion is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions? 1 Restrict fluids during mealtimes. 2 Discontinue the use of salt when cooking. 3 Provide high-calorie foods between meals. 4 Eliminate whole-milk products from the diet.

3 Provide high-calorie foods between meals. The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? Select all that apply. 1. "I plan to start taking vitamin B6 with breakfast." 2. "I'll still be taking this drug 6 months from now." 3. "I sometimes allow our children to sleep in our bed at night." 4. "I know I also have tuberculosis because the skin test was positive." 5. "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

3. "I sometimes allow our children to sleep in our bed at night." 4. "I know I also have tuberculosis because the skin test was positive." 5. "I'll be skipping the wine but enjoying the cheese at my neighbor's party." The children are at an increased risk because the client's spouse has TB; the children should be screened as members of the household. The positive skin test indicates that the client has been exposed to the bacilli and developed antibodies, not necessarily the disease itself; further diagnostic studies are indicated. Both wine and aged cheese contain tyramine and histamine, which when taken concurrently with INH can cause headache, flushing, and a drop in blood pressure; these should be avoided when taking INH. Pyridoxine (vitamin B6) should be taken to prevent neuritis, which is associated with INH. The prophylactic drug therapy will be continued for 6 to 12 months.

A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1. Sprinkle the powder from the capsule into a cup of water. 2. Insert a rectal suppository containing 100 mg of phenytoin. 3. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. 4. Obtain a change in the administration route to allow an intramuscular injection

3. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. When an oral medication is available in a suspension form, the nurse can use it for clients who cannot swallow capsules. Use the "Desire over Have" formula to solve the problem. Desire 100 mg = x mL Have 125 mg 5 mL 125x = 500 X = 500 ÷ 125 X = 4 mL. Because a palatable suspension is available, it is a better alternative than opening the capsule. The route of administration cannot be altered without the healthcare provider's approval. Intramuscular injections should be avoided because of risks for tissue injury and infection.

A client with advanced cancer of the bladder is scheduled for a cystectomy and ileal conduit. What intervention does the nurse anticipate the healthcare provider will prescribe to prepare the client for surgery? 1. Intravesicular chemotherapy 2. Instillation of a urinary antiseptic 3. Administration of an antibiotic 4. Placement of an indwelling catheter

3. Administration of an antibiotic Intestinal antibiotics and a complete cleansing of the bowel with enemas until returns are clear are necessary to reduce the possibility of fecal contamination when the bowel is resected to construct the ileal conduit. Intravesicular chemotherapy is unnecessary because the urinary bladder is removed with this surgery. Instillation of a urinary antiseptic is not necessary. There is no evidence of a urinary tract infection. The urinary bladder will be removed, so there is no need for an indwelling urinary catheter. No data indicate that the client is experiencing urinary retention before surgery.

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? 1. Reduce the intake of protein-rich foods 2. Drink 8 ounces (240 mL) of water with meals 3. Divide the daily caloric intake into six smaller meals 4. Remain in an upright position for one hour after eating

3. Divide the daily caloric intake into six smaller meals The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.

Client Chart HCP progress note: client has stage III RA, which is progressively causing more joint deformity, stiffness, and pain. Nurse's H&P: Client has ulnar drift on both hands and hallux valgus deformity of both feet. Client reports pain when walking and joint stiffness for several hours in the moraning, particularly the small joints of the hands and feet. Joints of the hand reflect signs and symptoms of inflammation (heat, swelling, tenderness). Lab results: rheumatoid factor (RF): 1:70 (positive for RA) ESR: 40 mm/hr c-reactive protein (CRP): 20 mg/dL WBC: 13, 000/uL A nurse is caring for a client attending a community-based health center and reviews the client's medical record. What should the nurse encourage the client to do? 1. Wring a sponge repeatedly when washing dishes. 2. Install faucets that require turning rather than pushing. 3. Push with the palms rather than the fingers when rising from a chair. 4. Actively use the hands for several hours each morning, sewing or knitting.

3. Push with the palms rather than the fingers when rising from a chair. Pushing off with the palms of the hands rather than the fingers uses the strongest joints available to rise from a chair. Pressing water from a sponge rather than wringing maintains the joints of the hands in a neutral position. Wringing a sponge requires finger flexion, which places strain on the joints of the hand. The client with ulnar drift deformities of both hands should have faucets and doorknobs that require pushing rather than turning. Pushing exerts less stress on the joints of the hands during routine activities. Turning a doorknob or faucet requires grasping and twisting motions that strain the small joints of the hands. An ulnar drift deformity limits the ability to grasp small objects. Sewing projects require gripping a needle or hook as well as repetitive motions that should be avoided because they strain the joints of the hands.

When providing discharge teaching to a client who had a total hip replacement, what should the nurse instruct the client to avoid? 1. Climbing stairs 2. Stretching exercises 3. Sitting in a low chair 4. Lying prone for more than 15 minutes

3. Sitting in a low chair Excessive flexion of the hip can cause dislocation of the femoral head. Climbing stairs should not cause undue strain on the operative site. Stretching exercises should be encouraged as long as no extremes of position are implemented. The client is permitted to lie prone for more than 15 minutes; lying prone should be encouraged because it prevents hip flexion contractures.

A nurse is teaching a school-aged child how to use an insulin pump. What is most important for the child to understand? 1. The needle must be changed every day. 2. A blood glucose check is necessary once a day. 3. The pump is an attempt to mimic the way a healthy pancreas works. 4. Subcutaneous pockets near the abdomen are used to implant the pump.

3. The pump is an attempt to mimic the way a healthy pancreas works. The basal infusion rate mimics the low rate of insulin secretion during fasting, and the bolus before meals mimics the high output after meals. The subcutaneous needle and tubing may be left in place for as long as three days. Blood glucose monitoring is performed at least four times a day. Most insulin pumps are battery-driven syringes external to the body.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? 1 "There are no dietary restrictions because the tumor has been removed." 2 "Your diet should be low in calories to prevent taxing your diseased pancreas." 3 "Meals should be restricted in protein because of your compromised liver function." 4 "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."

4 "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism." Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine and interruption of glucose metabolism; interference with fat digestion occurs. Clients require small, frequent low-fat, high-protein, moderate-carbohydrate meals and supplemental feedings. The response "There are no dietary restrictions because the tumor has been removed" is false reassurance. High-calorie meals are needed to provide energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless metastasis occurs by direct extension.

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? 1 Blood clotting 2 Bone formation 3 Muscle contraction 4 Cellular membranes

4 Cellular membranes Cholesterol is an essential structural and functional component of most cellular membranes. That it is associated with atherosclerotic plaques does not detract from its essential functions. Cholesterol is not necessary for blood clotting; calcium and vitamin K are necessary. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are necessary. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are necessary.

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? 1 Empty feeding bag stays attached to the tubing. 2 Tube is flushed with air after medication is given. 3 Replacement of the tube is done on a weekly basis. 4 Head of the bed remains elevated after the feeding.

4 Head of the bed remains elevated after the feeding. The client's upper body must be elevated to prevent aspiration and promote digestion. Attaching the empty feeding bag to the tubing is not necessary. The end of the gastrostomy tube just needs to be covered. The tube is flushed with water, not air, before and after food or medication is given; excess air in the gastrointestinal tract can cause abdominal distention and cramping. Because the tube was inserted by a surgical procedure, it is replaced only when a problem is identified, and usually only by the healthcare provider.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? 1 Increased fiber intake 2 Bacterial contamination 3 Inappropriate positioning 4 High osmolarity of the feedings

4 High osmolarity of the feedings The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

An x-ray film indicates that an older client has a fractured femur. The client asks the nurse, "Will I be able to walk again?" What is the best response by the nurse? 1. "I have no idea because only time will tell." 2. "You only broke a bone. It could have been worse." 3. "You'll walk again. This is a common issue in older people." 4. "Tell me more about your concerns about being able to walk."

4. "Tell me more about your concerns about being able to walk." The phrase "Tell me more" shows interest in the client's concerns, is nonjudgmental, and encourages expression and exploration of feelings. First the client's feelings must be explored before providing a direct answer that may cut off communication. The responses "I have no idea" and "You only broke a bone. It could have been worse" places the client on the defensive; it is demeaning to the client and discourages further communication. The general response "You'll walk again. This is a common issue in older people" dismisses the client's concerns; the client is not recognized as an individual whose injury is a traumatic and personal event.

A pregnant client states to the nurse, "I have been advised to take an over-the-counter medication for the flu. The drug label says it is a category B drug." How should the nurse respond to these statements? 1. "Because this drug causes fetal abnormalities, you should not take this drug." 2. "This drug causes fetal risks when administered and should not be used in pregnancy." 3. "This drug has been reported to have adverse effects in animal fetuses so this drug should be avoided." 4. "This drug does not show risks to an animal fetus so you can safely take it while pregnant."

4. "This drug does not show risks to an animal fetus so you can safely take it while pregnant." According to the Food and Drug Administration, category B drugs have no risk to an animal fetus. Therefore these medications are safe to take during pregnancy. Studies report that category X drugs cause fetal abnormalities and should be avoided. Category D drugs are reported to cause adverse effects in animal fetuses so pregnant clients should avoid these drugs. Category C drugs have been shown to have adverse effects in animal fetuses.

A 16-year-old adolescent with recently diagnosed type 1 diabetes will receive NPH insulin subcutaneously. The nurse teaches the adolescent about peak action of the drug and the risk for hypoglycemia. How many hours after NPH insulin administration does the insulin peak? 1. 1 to 2 hours 2. 2 to 4 hours 3. 5 to 10 hours 4. 4 to 12 hours

4. 4 to 12 hours NPH insulin peaks in 4 to 12 hours; it has an onset time of 1.5 to 4 hours and a duration of 18 to 24 hours. NPH insulin does not peak 1 to 2 hours, 2 to 4 hours, or 5 to 10 hours after administration.

The nurse is preparing a community education session about the family emergency preparedness kit. Which information should the nurse include in the teaching plan? Select all that apply. A. The kit should be sufficient for 1 day. B. Matches should be included in a waterproof container. C. Cereal bars and peanut butter crackers should be included. D. Insect repellents and deodorants should be avoided. E. Household liquid bleach and resealable plastic bags should be included

B. Matches should be included in a waterproof container. C. Cereal bars and peanut butter crackers should be included. E. Household liquid bleach and resealable plastic bags should be included The family emergency preparedness kit provides basic supplies in the event of unexpected dangers such as natural disasters. While preparing this kit, the individual should include matches in a waterproof container. Nonperishable foods such as cereal bars and peanut butter crackers should also be kept in the kit. Household liquid bleach can be included and used for disinfection, and resealable plastic bags should be also be kept in the kit. The family emergency preparedness kit should be sufficient for at least 3 days, not 1 day. Insect repellents and deodorants should be included in the kit.