COMP Exam Study Questions
A positive Babinski's signs is present in infants until approx. what age?
1 year of age this is normal in neonates but abnormal in adults
A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first? 1. Heart rate, respiratory rate, and blood pressure 2. Recent exposure to communicable diseases 3. Number of immunizations received 4. Height and weight
1. Heart rate, respiratory rate, and blood pressure RATIONALE: The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather data about disease exposure, immunizations, and height and weight later.
a patients receiving doxycycline as a short term therapy for malaria which should nurse include in teaching plan
1.) avoid exposure to the sun by wearing protective clothing
What should be the initial bolus of crystalloid fluid replacement for a child in shock? 1. 10 ml/kg 2. 15 ml/kg 3. 20 ml/kg 4. 30 ml/kg
3. 20 ml/kg RATIONALE: Fluid volume replacement must be calculated using the child's weight to avoid overhydration. Initial fluid bolus is administered at 20 ml/kg, followed by another 20 ml/kg bolus if there is no improvement in fluid status.
At what gestational age is a conceptus considered viable (able to live outside the womb)? 1. 9 weeks 2. 14 weeks 3. 24 weeks 4. 30 weeks
3. 23 / 24 weeks the lungs are developed enough to sometimes maintain extrauterine life. the lungs are the most immature system during the gestational period. medical care for premature labor begins much earlier (aggressively at 21 weeks0
After a head injury, a child experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of: 1. hypercalcemia. 2. hyperglycemia. 3. hyponatremia. 4. hypokalemia.
4. hypokalemia. RATIONALE: Enuresis, polydipsia, and weight loss suggest diabetes insipidus, a disorder that may result from a head injury that damages the neurohypophyseal structures. Diabetes insipidus places the child at risk for fluid volume depletion and hypokalemia. Diabetes insipidus doesn't cause hypercalcemia, hyperglycemia, or hyponatremia.
When does NPH insulin peak?
6 - 12 hours
A client is preparing for surgery and nurse would tell the client not to take solicitations how many days before surgery
7
The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%
A Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.
Which of the following is the most common symptom of myocardial infarction (MI)? A) Chest pain B) Dyspnea C) Edema D) Palpitations
A) Chest pain The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after an MI. Palpitations may result from reduced cardiac output, producing arrhythmias.
What is the amount of weight gain normal for the third trimester? A. 8-12 pounds B. 12-14 pounds C.5-10 pounds D. 1-20 pounds
A. 8-12 pounds
Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: a. Alteration in tissue perfusion related to compromised circulation b. Dysfunctional use of extremities related to muscle spasms c. Impaired mobility related to stress associated with pain d. Impairment in muscle use associated with pain on exertion.
A. Alteration in tissue perfusion related to compromised circulation
Select all of the complications associated with chorionic villus sampling. A. bleeding B. premature labor C. amniotic embolism D. rupture of membranes E. infection F. spontaneous abortion
A. bleeding D. rupture of membranes F. spontaneous abortion
What physiological conditions are contraindicated for using heat as a therapy? (Select all that apply.) 1. The first 24 hours of injury 2. Active hemorrhage 3. Noninflammatory edema 4. Localized malignant tumor
All of the above; Heat causes vasodilatation and increases blood flow to the affected area bringing oxygen, nutrients, antibodies, and leukocytes. A possible disadvantage of heat is that it increases capillary permeability, which allows extracellular fluid and substances to pass through the capillary walls and may result in edema or an increase in preexisting edema. Contraindications include: the first 24 hours of injury, active hemorrhage, noninflammatory edema, localized malignant tumor, and skin disorder that causes redness or blisters.
Because uteroplacental circulation is compromised in clients with preeclampsia, a NST is performed to detect which conditions? 1. Anemia 2. Fetal well being 3. IUGR 4. oligohydarminos
An NST is based on the theory that a healthy fetus will have transient fetal heart rate accelerations with fetal movement. A fetus with compromised uteroplacental circulation usually wont have these accelerations, which indicate a nonreactive NST. Serial US wil detect IUGR and oligohydramnios in a fetus. An NST cant detect anemia in a fetus
1).The nurse is taking the social history of a client diagnosed with SCLC (Single Cell Lung Cancer).Which information is significant for this disease? 1. Worked with asbestos for a short time many years ago. 2. Has no family Hx of this type of lung cancer. 3. Has numerous tattoos on upper and lower arms. 4. Has smoked 2 packs of cigarettes/day for 20 years.
Answer: 4- Has smoked 2 packs of cigarettes/day for 20 years. Rational: Smoking is greatest risk for LC.
When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A. Increase red meat in the diet. B. Consume melons and baked potatoes. C. Add several portions of dairy products each day. D. Try replacing your usual breakfast with oatmeal or Cream of Wheat.
B Melons and baked potatoes contain potassium. Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron; oatmeal contains fiber but not potassium
If a lymph node is palpated, what is a normal finding? a. hard, fixed nodes b. firm, mobile nodes c. enlarged, tender nodes d. hard, non tender nodes
B - Ordinarily, lymph nodes are not palpable in adults. If a node is palpable, it should be small (0.5 to 1 cm), mobile, firm, and nontender to be considered a normal finding.
Aspirin is administered to the client experiencing an MI because of its: A) Antipyrectic action B) Antithrombotic action C) Antiplatelet action D) Analgesic action
B) Antithrombotic action Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason ASA is administered to the client experiencing an MI is its antithrombotic action.
What are the common cancers related to tobacco use? (Select all that apply.) A. Cardiac cancer B. Lung cancer C. Cancer of the tongue D. Skin cancer E. Cancer of the larynx
B, C, E Organs exposed to the carcinogens in tobacco (lungs, tongue, larynx) are the most likely to develop cancer. Oral cancer is also a risk with "smokeless" tobacco. The heart does not contain cells that divide; therefore, cardiac cancer is unlikely. Skin cancer generally is related to repeated sun and other ultraviolet exposure, such as that found with tanning beds.
Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? A. "Elevate your legs above heart level to prevent swelling." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Walk to the point of leg pain, then rest, resuming when pain stops." D. "Apply a heating pad to the legs if they feel cold."
C Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.
What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability? a. call the physician b. administer insulin as ordered c. check the patient's blood glucose level d. assess for other neurologic symptoms
C - Blood glucose testing should be performed whenever hypoglycemia is suspected so that immediate action can be taken if necessary.
The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? a. 8:40 PM to 9:00 PM b. 9:00 PM to 11:30 PM c. 10:30 PM to 1:30 AM d. 12:30 AM to 8:30 AM
C - Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10-30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.
Patient with Hodgkin's lymphoma angrily tells the nurse, "I want my treatment started. I am tired of all of these tests. Now my Dr. wants to stage my disease." The nurse should respond by explaining that staging: A. Involves cell differentiation B. Is the treatment modality C. Involves categorizing the disease extension D. Can be determined after treatment is initiated
C. Involves categorizing the disease extension
Who much weight should a pregnant mother with a BMI of 30 gain? A. 28-40 pounds B.15-25 pounds C.11-20 pounds D. 25-35
C.11-20 pounds
Tx for DKA: Find the ________. Give _________ blood sugar and ____________. Give IV _________. Monitor _ _ _ and _ _ _'s and hourly _______.
Cause / hourly (checks?)/ potasium (k+) - bc insulin carries glucose and k into the cell / IV insulin -it decreases the potassium and glucose levels by driving it into the cell / ECG and ABG's / output (for good kidney profusing)
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. "I don't know." b. "Is that the right answer?" c. "Wait, let me think about that." d. "Who are those people over there?"
Correct Answer: A Rationale: Answers such as "I don't know" are more typical of depression. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.
In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) A. Maintaining a clean technique for all invasive procedures. B. Placing the client in protective isolation. C. Limiting visitors who have colds and infections. D. Ensuring meticulous hand washing by all persons coming in contact with the client.
Correct Answers: B, C, D Rationale: Chronic lymphoid leukemia (CLL) is characterized by a proliferation and accumulation of small, abnormal mature lymphocytes in bone marrow, peripheral blood, and body tissues. Infections and fever are frequent complications of CLL.
Antiretroviral drugs are used to a. cure acute HIV infection. b. decrease viral RNA levels. c. treat opportunistic diseases. d. decrease pain and symptoms in terminal disease.
Correct answer: b Rationale: The goals of drug therapy in HIV infection are to (1) decrease the viral load, (2) maintain or raise CD4+ T cell counts, and (3) delay onset of HIV infection-related symptoms and opportunistic diseases.
The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease? 1. Involvement of a single lymph node. 2. Involvement of two or more lymph nodes on the same side of the diaphragm. 3. Involvement of lymph node regions on both sides of the diaphragm. 4. Diffuse disease of one or more extralymphatic organs
Correct: 1. In the staging process, the designations A and B signify, respectively, that symptoms were or were not present when Hodgkin's disease was found. The Roman numerals I through IV indicate the extent and location of involvement of the disease. Stage I indicates involvement of a single lymph node; stage II, two or more lymph nodes on the same side of the diaphragm; stage III, lymph node regions on both sides of the diaphragm; and stage IV, diffuse disease of one or more extralymphatic organs.
33. A with tumor lysis syndrome (TLS) is taking allopurinol (Xyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication? a. Blood urea nitrogen (BUN) b. Serum phosphate c. Serum potassium d. Uric acid level
D Rationale: Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are also increased in TLS but are not affected by allopurinol therapy.
6. When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is staged as Tis, N0, M0. The nurse will teach the patient that a. the cancer cells are well-differentiated. b. it is difficult to determine the original site of the cervical cancer. c. further testing is needed to determine the spread of the cancer. d. the cancer is localized to the cervix.
D Rationale: Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.
A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and symptoms would the client show if therapy is inadequate? A Decreased shortness of breath B Improved chest x-ray C Nonproductive cough D Positive acid-fast bacilli in a sputum sample after 2 months of treatment
D) Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection.
What changes in the thyroid gland do we see in aging people?
Glandular atrophy Decreased function Hypothyroidism Slower metabolism
30/70 and 50/50 premixed insulin preperations are for what? This can be helpful for whom?
To eliminate the need to combine 2 types of insulin in one syringe. / For those who self administer.
The client should eat when insulin is:
at it's peak
Main role of surfactant in the neonate
helps the lungs remain expanded after the initiation of breathing works by reducing surface tension in the lung allows the lung to remain slightly expanded decreases amount of work required for inspiration
avoid fasting as it causes ___________. avoid feasting as it causes _____________.
hypoglycemia / hyperglycemia
Anything that ____________ blood sugar can throw a client into DKA. Examples are:
increases / (infection, illness or skipping insulin)
normally when someone gets sick or stressed the __________ can handle the fluctations by releasing amounts of insulin to carry the extra sugar into the cell - when the body gets excited it released steriods - sugar is an anti-inflammatory that actually puts you more at risk for infection so, the insulin takes it out of the blood stream.
pancreas
What is the term that refers to the number of pregnancies that are beyond 20 weeks whether dead or alive?
para
Where do you place the stethoscope to assess an apical pulse of a newborn?
place bell between 4th and 5th intercostal space, midclavicular line
A patient presenting to the ER with a hypertensive crisis (BP greater than 180/120), may have damage to which of the following? A. Brain B. Kidney C. Liver D. Heart E. Stomach F. Eyes
A, B. D. F CVA retinopathy heart failure renal failure IV beta blocker will be ordered immediately for a pt in a hypertensive crisis
When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor
A, C, D Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count. Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.
The nurse explains to a client that which risk factor of those listed most likely contributed to the client's primary liver carcinoma? A. Infection with hepatitis B virus B. Consuming a diet high in animal fat C. Exposure to radon D. Familial polyposis
A. Infection with hepatitis B virus Hepatitis B and C are risk factors for primary liver cancer. Alcohol abuse is also a risk factor for the development of liver cancer. Consuming a diet high in animal fat may predispose a person to colon or breast cancer. Exposure to radon is a risk factor for lung cancer.
Pregnant women should avoid antacids that contain with electrolyte? A. calcium B. Sodium C. phosphorus D. magnesium
A. calcium
A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.
Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem? A Nonproductive or productive cough B Anorexia and weight loss C Chills and night sweats D High-grade fever
D) The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.
The nurse realizes that which is the laboratory test ordered to determine the presence of the amino acid that can contribute to cardiovascular disease and stroke? a. antidiuretic hormone b. homocysteine c. ceruloplasmin d. cryoglobulin
b. homocysteine
The nurse knows that which diuretic is most frequently combined with an antihypertensive drug? a. chlorthalidone b. hydrochlorothiazide c. bendroflumethiazide d. potassium-sparing diuretic
b. hydrochlorothiazide
Which of the following fetal positions is most favorable for birth? 1. Vertex 2. Transverse lie 3. Frank breech presentation 4. Posterior position of the head
1. Vertex presentation flexion of the fetal head is the optimal presentation for passage thru the birth canal. Transverse lie is an unacceptable fetal position for vaginal birth and requires c-section frank breech presentation, in which the buttocks presents first, can be difficult vaginal delivery. posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis.
An otherwise-healthy adolescent is hospitalized for diabetic ketoacidosis and is receiving I.V. and oral fluids. The nurse should monitor his fluid intake because quick fluid replacement or fluid overload may cause: 1. cerebral edema. 2. dehydration. 3. heart failure. 4. hypovolemic shock.
1. cerebral edema. RATIONALE: Quick fluid replacement or fluid overload would make the adolescent vulnerable to developing cerebral edema and increased intracranial pressure. Quick fluid replacement or fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood, not a fluid overload.
a nurse is preparing a plan of care for a client whos prescribed an antiparasitic agent which diagnosis would be most related to drug therapy
1.) Diarrhea 2.) risk for deficient fluid volume
A nurse is preparing to administer penicillin therapy. The nurse would expect to administer penicillin cautiously to clients with which of the following
1.) History allergies 2.) Asthma 3.) Bleeding disorders
a nurse suspects that a client is experiencing acute acetaminophen toxicity based on assessment of which
1.) nausea 2.)jaundice 3.) cardiac arrhythmia 4.) confusion
A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? 1. Within hours 2. Within 2 weeks 3. Within 1 month 4. After induction therapy is completed
2. Within 2 weeks RATIONALE: Bone marrow depression is most likely to occur 10 days after methotrexate is administered.
A complication of the hyperviscosity of polycythemia is: a. thrombosis b. cardiomyopathy c. pulmonary edema d. disseminated intravascular coagulation (DIC)
A - The patient with polycythemia may experience angina, heart failure, intermittent claudication, and thrombophlebitis, which may be complicated by embolization. These manifestations are caused by blood vessel distention, impaired blood flow, circulatory stasis, thrombosis, and tissue hypoxia, caused by the hypervolemia and hyperviscosity. The most common serious acute complication is stroke, caused by thrombosis.
The patient understand that which of the following are factors that he can change to decrease his risk of HTN? Select All That Apply A. smoking B. family history C. Alcohol consumption D. increased LDL E. Sedentary lifestyle
A, C. D, E Pt can change all but his family history
The silent killer, essential HTN, sometimes doesn't have obvious s/s, but some that may be reported by the patient include: Select All That Apply A. Dizziness B. Kidney disease C. Headache D. Syncope (fainting) E. Hot/flushed F. Nose bleed (epistaxis) G. Diabetes
A, C. D, E, F Kidney disease and diabetes are not s/s and are a factor in secondary HTN, not primary
A 2-month-old infant hasn't received any immunizations. Which immunizations should the nurse prepare to administer? 1. Measles, mumps, rubella (MMR); diphtheria, tetanus toxoids, and acellular pertussis (DTaP); and hepatitis B (HepB) 2. Polio (IPV), DTaP, MMR 3. Varicella, Haemophilus influenzae type b (HIB), IPV, and DTaP 4. HIB, DTaP, HepB, IPV, and pneumococcal conjugate vaccine (PCV)
4. HIB, DTaP, HepB, IPV, and pneumococcal conjugate vaccine (PCV) RATIONALE: The current immunizations recommended for a 2-month-old who hasn't received any immunizations are HIB, DTaP, HepB, PCV, and IPV. The first immunizations for MMR and varicella are recommended when a child is age 12 months.
distribute food intake to __ small meals a day to maintain blood sugar level and prevent sudden surges in blood sugar
6
7. Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the patient understands the purpose of a biopsy? a. "The biopsy will tell the doctor whether the cancer has spread to my other organs." b. "The biopsy will help the doctor decide what treatment to use for my enlarged prostate." c. "The biopsy will determine how much longer I have to live." d. "The biopsy will indicate the effect of the cancer on my life."
B Rationale: A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. Biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life; the three remaining statements indicate a need for patient teaching.
15. A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine
B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. Cognitive Level: Application Text Reference: p. 1260 Nursing Process: Planning NCLEX: Physiological Integrity
During history taking of a client admitted with newly diagnosed Hodgkin's disease, which of the following would the nurse expect the client to report? a) weight gain B) night sweats C) Severe lymph node pain D) Headache with minor visual changes
B - Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes, fever, malaise, and night sweats. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.
A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? a. start IV fluids. b. maintain oxygenation. c. maintain distal warmth. d. check peripheral pulses.
B - Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.
What will caring for a patient with a diagnosis of polycythemia vera likely require the nurse to do? a. encourage deep breathing and coughing. b. assist with or perform phlebotomy at the bedside. c. teach the patient how to maintain a low-activity lifestyle. d. perform thorough and regularly scheduled neurologic assessments.
B - Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.
A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is: A A bloody, productive cough B A cough with the expectoration of mucoid sputum C Chest pain D Dyspnea
B) One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.
What is the first intervention for a client experiencing myocardial infarction (MI) ? A) ADMINISTER MORPHINE B) ADMINISTER OXYGEN C) ADMINISTER SUBLINGUAL NITROGLYCERIN D) OBTAIN AN ELECTROCARDIOGRAM (ECG
B) ADMINISTER OXYGEN ADMINSTERING SUPPLEMENTAL OXYGEN TO THE CLIENT IS THE NUMBER ONE PRIORITY OF CARE.
Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? A) Decrease anxiety B) Enhance myocardial oxygenation C) Administer sublingual nitroglycerin D) Educate the client about his symptoms
B) Enhance myocardial oxygenation Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised.
The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? (Select all that apply.) A. Limit sodium intake. B. Avoid beef and processed meats. C. Increase consumption of whole grains. D. Eat "colorful fruits and vegetables," including greens. E. Avoid gas-producing vegetables such as cabbage.
B, C, D Consuming bran and whole grains and avoiding red meat and processed foods such as lunchmeats can reduce cancer risk. Consuming foods high in vitamin A, including apricots, carrots, and leafy green and yellow vegetables, can also reduce cancer risk. Reducing sodium is helpful in the treatment of hypertension and heart and kidney failure; no evidence suggests that lowering of sodium intake decreases the incidence of cancer. Eating cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage may actually reduce cancer risk.
You are taking care of a male patient who has the following laboratory values from his CBC: WBC 6.5x10(3)/uL, Hgb 13.4 g/dL, Hct 40%, platelets 50x10(3)/uL. What are you most concerned about? a. your patient is neutropenic b. your patient has an infection c. your patient is at risk for bleeding d. your patient is at fall risk due to his anemia
C - The patient complete blood cell count (CBC) has normal parameters except for the platelet count, which is below normal.
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.
Correct Answer: D Rationale: The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
A nurse feels that a 5-year-old boy in her care is showing signs and symptoms of diabetes mellitus. The nurse should: 1. gather supporting evidence and contact the physician with her concerns. 2. ask the dietitian to talk with the child and his parents about a diabetic diet. 3. ask the laboratory to perform a random glucose test. 4. monitor the child's activity for 24 hours.
1. gather supporting evidence and contact the physician with her concerns. RATIONALE: If a nurse suspects a diagnosis, she must evaluate the situation further and collect more data. Then she should present her findings to the physician. It isn't appropriate for the nurse to wait 24 hours before addressing the possible diabetes. It would be premature for the nurse to contact the dietitian about a diabetic diet, and a nurse doesn't have authority to order a random glucose test.
Which of the following changes in resp functioning during pregnancy is considered normal? 1. increased tidal volume 2. increases expiratory volume 3. decreased inspiratory capacity 4. decreased oxygen consumption.
1. increased tidal volume a pregnant client breathes deeper, which increases the tidal volume of gas moved in and out of the respiratory tract w/ each breath. The expiratory volume and residual volume DECREASE as the preg. progresses. The inspiratory capacity INCREASES during preg. The increases oxygen consumption in the preg client is 15-20% greater than in the nonpreg state
A nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should emphasize the fact that: 1. most toddler deaths are accidental. 2. medication overdose is the leading cause of death in toddlers. 3. any infant older than age 12 months can safely ride in a front-facing car seat. 4. a toddler's risk of injury is the same as that of an adult.
1. most toddler deaths are accidental. RATIONALE: Most toddler deaths are accidental. Many injuries or deaths in this age-group result from fire, drowning, motor vehicle accidents, and firearms. Toddlers don't generally overdose on medications, although this situation could happen if a toddler were given too much medication in the home or hospital setting. A child must be older than age 12 months and weigh more than 20 lb (9.1 kg) to ride in a front-facing car seat. Toddlers are at higher risk for injury than adults because of their developmental level and their limited ability to distinguish right from wrong and to recognize danger signs.
An 8-year-old child is receiving moderate sedation for a medical procedure. The nurse is assessing the child's level of sedation. His gag reflex is intact, he's breathing comfortably on his own, and he opens his eyes on verbal request. The nurse recognizes that the child is: 1. undersedated. 2. appropriately sedated. 3. deeply sedated. 4. oversedated.
2. appropriately sedated. RATIONALE: Moderate sedation is an induced state of depressed consciousness. While under moderate sedation, the child should maintain protective reflexes (such as the gag reflex), maintain a patent airway independently, and respond to physical stimuli or verbal commands such as, "Open your eyes." In this scenario, the nurse assesses that the child is under moderate sedation. An undersedated child would likely be anxious and would complain of pain. In deep sedation, the child isn't as easily aroused and doesn't have protective reflexes or the ability to maintain a patent airway; this type of sedation is closer to general anesthesia. With oversedation, the child is difficult to rouse; however, he is able to maintain a patent airway independently.
Lochia alba follows lochia serosa and usually lasts from the 1st to 3rd week PP. Which of the following statements best describes lochia alba? 1. creamy white-brown, stale odor 2. creamy white to brown, contains decidual cells, may have stale odor 3. brown to red, tissue fragments, odor 4. brown to red contains decidual cells and leukocytes
2. creamy white to brown, contains decidual cells, may have stale odor also contais leukocytes but it shouldnt contain tissue fragments or have a foul odor
When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which restraint system would be safest? 1. A front-facing convertible car seat in the middle of the back seat 2. A rear-facing infant safety seat in the front passenger seat 3. A rear-facing infant safety seat in the middle of the back seat 4. A front-facing convertible car seat in the back seat next to the window
3. A rear-facing infant safety seat in the middle of the back seat RATIONALE: Infants from birth to 20 lb (9.1 kg) and younger than age 1 must be in a rear-facing infant or convertible seat in the back seat, preferably in the middle. Infants and small children should never be placed in the front seat because of the risk of injuries from a breaking front windshield and an expanding airbag. Positioning a car seat next to the window isn't preferred.
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following? 1. The area proximal to the fracture. 2. The actual fracture site. 3. The area distal to the fracture. 4. The opposite extremity for baseline comparison.
3. The nursing assessment is first focused on the region distal to the fracture for neurovascular injury or compromise. When a nerve or blood vessel is severed or obstructed at the actual fracture site, innervation to the nerve or blood flow to the vessel is disrupted below the site; therefore, the area distal to the fracture site is the area of compromised neurologic input or vascular flow and return, not the area above the fracture site or the fracture site itself. The nurse may assess the opposite extremity at the area proximal to the fracture site for a baseline comparison of pulse quality, color, temperature, size, and so on, but the comparison would be made after the initial neurovascular assessment.
Which of the following would nurse orderto a client experiencing opioid induced respiratory depression
NAloxone
Should you aspirate insulin shots? Why?
NO / B/C it damages tissue - if you aspirated, it would cause tissue trauma.
A child, age 5, is diagnosed with chronic renal failure. When teaching the parents about diet therapy, the nurse should instruct them to restrict which foods from the child's diet? 1. Meats 2. Carbohydrates 3. Fats 4. Dairy products
1. Meats RATIONALE: The nurse should instruct the parents to restrict meats because they contain a large amount of protein. Dairy products, carbohydrates, and fats are appropriate food choices for this child.
When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging? 1. Thinning of the epidermis 2. Thickening of the epidermis 3. Oiliness of the skin 4. Increased elasticity of the skin
1. Thinning of the epidermis, The epidermis thins with aging, and there is decreased strength and elasticity of the skin, increased dryness and scaliness of the skin, and diminished pain perception due to decreased sensation of pressure and light touch.
Sites for injection should be spaced about ____ _____ apart. This is in order to avoid sudden changes in absorption rate
ONE INCH
What is a normal systolic blood pressure for a 3-year-old child? 1. 60 mm Hg 2. 93 mm Hg 3. 120 mm Hg 4. 150 mm Hg
2. 93 mm Hg RATIONALE: The normal range for systolic blood pressure in preschoolers is 82 to 110 mm Hg. The normal range for diastolic blood pressure is 50 to 78 mm Hg.
Which toy is appropriate for a 3-year-old child? 1. A bicycle 2. A puzzle with large pieces 3. A pull toy 4. A computer game
2. A puzzle with large pieces RATIONALE: A puzzle is the most appropriate toy because, at age 3, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5- or 6-year-old child; a pull toy, for a toddler; and a computer game, for a school-age child.
An ultrasound can be performed as early as how many weeks?
5 weeks
When can a chronic villus test be performed?
8-12 weeks
The Causative agent of Tuberculosis is said to be: A Mycobacterium Tuberculosis B Hansen's Bacilli C Bacillus Anthracis D Group A Beta Hemolytic Streptococcus
A)
9) Which of the following nursing diagnoses is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? A. Acute pain B. Hypothermia C. Powerlessness D.Risk for infection
Answer: D - Risk for infection
The majority of people over 65 have PVD? A. True B. False
B. False
When drawing up regular and NPH, which one do you draw up first?
Clear/regular and then NPH/cloudy
What are S/Sx of hypoglycemia
Cold and Clammy, increased HR and pulse / Headache / confusion / shaky / nervous and nauseous
What is Naegele's Rule?
Count back Nagele's Rule, add 7 days to first day of period and one year
When is a AFP test performed? A. 8-12 weeks B. 16 weeks C. 5 weeks D. 16-18 weeks
D. 16-18 weeks
Exercise when blood sugar is at its highest or lowest
Highest - it's not smart to run if your blood sugar is low
Remember not to mix _______ with anything!
Lantus
How should a nurse prepare a suspension before administration? 1. By diluting it with normal saline solution 2. By diluting it with 5% dextrose solution 3. By shaking it so that all the drug particles are dispersed uniformly 4. By crushing remaining particles with a mortar and pestle
3. By shaking it so that all the drug particles are dispersed uniformly RATIONALE: The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form.
What is turner's syndrome?
a chromosomal alteration deficit in which a female is born with only one X
What option offers better control? pump or shot of insulin?
pump
Injectable glucagon (GlucaGen) is used when? How is it given?
when there is no IV access / IM
A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as: 1. Abrasion 2. Unapproximated 3. Laceration 4. Eschar
3. Laceration; Laceration best describes the wound, because skin is ripped off. An abrasion is a scrape. Unapproximated is a general term for a wound that is not closed. Eschar is a scab-like covering over a wound.
Which of the following conditions isnt dx by abdominal US during the prenatal period? 1. fetal presentation 2. fetal heart activity 3. maternal diabetes 4. amniotic fluid volume
3. maternal diabetes abdominal US evals fetal presentation, fetal heart activity, amniotic fluid volume although it may show increased amnitoic flud, thus helping to diagnose maternal diabetes, it isnt used for that purpose.
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry Gauze 3. Hydrocolloid 4. No dressing indicated.
3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.
A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? 1. Hypocalcemia 2. Hypercalcemia 3. Hypokalemia 4. Hyperkalemia
3. Hypokalemia RATIONALE: The nurse should monitor the client receiving an I.V. infusion of terbutaline for hypokalemia, lactic acidosis, chest pain, arrhythmias, dyspnea, bloating, chills, or anaphylactic shock. Terbutaline doesn't cause calcium imbalances.
You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair, and the client reports that their skin damages easily. You would suspect that these signs and symptoms are related to: 1. Overuse of caustic products to strip the leg hair. 2. Chronic neurological pathology. 3. Impaired peripheral arterial circulation. 4. Inherited reduction in sweat glands and hair follicles.
3. Impaired peripheral arterial circulation; Shiny skin on the legs, reduction in or absence of leg hair, and skin that damages easily is often related to impaired peripheral arterial circulation.
A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the physician immediately? 1. Mouth breathing 2. Foul odor from the mouth 3. Moderate intercostal retractions 4. Irregular respirations while awake
3. Moderate intercostal retractions RATIONALE: Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician. Mouth breathing and a foul odor from the mouth aren't cause for concern. Irregular respirations while awake aren't an unusual finding in a young child.
A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which emotional response is typical during early adolescence? 1. Frequent anger 2. Cooperativeness 3. Moodiness 4. Combativeness
3. Moodiness RATIONALE: Moodiness may occur often during early adolescence. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.
Which toxic adverse reaction should the nurse monitor for in a toddler taking digoxin (Lanoxin)? 1. Weight gain 2. Tachycardia 3. Nausea and vomiting 4. Seizures
3. Nausea and vomiting RATIONALE: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures aren't findings in digoxin toxicity.
After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic suggests this diagnosis? 1. Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact) 2. Parents' active participation in child's physical or emotional care 3. Parents' expression of feelings of inadequacy in providing for their child's needs 4. Evidence of adaptation to parental role changes
3. Parents' expression of feelings of inadequacy in providing for their child's needs RATIONALE: Expression of feelings of inadequacy in providing for their child's needs is a defining characteristic of Parental role conflict related to child's hospitalization. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis.
A child, age 4, is brought to the clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal? 1. Light pink 2. Deep red 3. Pinkish gray 4. Yellowish white
3. Pinkish gray RATIONALE: The tympanic membrane normally appears pinkish gray, shiny, and translucent. A light pink, deep red, or yellowish white tympanic membrane is abnormal.
A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications? 1. Adolescents 2. Neonates 3. Premature infants 4. Toddlers
3. Premature infants RATIONALE: Factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs. Thus, the premature infant is at risk for problems because of immaturity. Deficiencies associated with immaturity become more important with decreasing age. Enzyme systems develop quickly, with most increasing to adult levels within 1 to 8 weeks after birth. Within the first year of life, all are probably as active as they will ever be.
A child, age 3, with lead poisoning is admitted to the facility for chelation therapy. The nurse must stay alert for which adverse effect of chelation therapy? 1. Anaphylaxis 2. Fever and chills 3. Seizures 4. Heart failure
3. Seizures RATIONALE: Chelation therapy removes lead by combining it with another substance to form a soluble compound that the kidneys can excrete. The nurse should stay alert for seizures because as lead is mobilized from bone and other tissues, the serum lead level rises rapidly, increasing the client's risk of seizures. Chelation therapy doesn't cause anaphylaxis, fever, chills, or heart failure.
An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During physical assessment, the nurse measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant? 1. Lying on the back 2. Lying on the abdomen 3. Sitting in an infant seat 4. Sitting in high Fowler's position
3. Sitting in an infant seat RATIONALE: Because the infant's assessment findings suggest that respiratory distress is developing, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion; an infant seat maintains this position. Placing an infant flat on the back or abdomen or in high Fowler's position could increase respiratory distress by preventing maximal chest expansion.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? 1. Total iron-binding capacity 2. Hemoglobin (Hb) 3. Total protein 4. Sweat test
3. Total protein RATIONALE: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.
While assessing a 2-month-old infant's airway, the nurse finds that he isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should: 1. attempt rescue breaths. 2. attempt to establish an airway a third time. 3. administer five back blows. 4. attempt to ventilate with a handheld resuscitation bag.
3. administer five back blows. RATIONALE: The nurse should clear the airway with back blows and chest thrusts. Attempting rescue breaths is futile because they can't be administered until the airway is patent. After two attempts to establish an airway, the nurse can assume the airway is blocked. The nurse can't attempt to ventilate the infant with a handheld resuscitation bag until the airway is patent.
A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: 1. as the infant plays. 2. as the infant sleeps. 3. as the mother feeds the infant. 4. as the mother rocks the infant.
3. as the mother feeds the infant. RATIONALE: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for example, the mother may interact with the infant at a distance whereas rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance.
A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first: 1. administer ipecac syrup. 2. call an ambulance. 3. call the poison control center. 4. punish the child for being bad.
3. call the poison control center. RATIONALE: Before intervening in any way, the parents should first call the poison control center for specific instructions. Ipecac syrup is no longer recommended for the ingestion of poisons. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.
A nurse-manager recognizes that infiltration commonly occurs during I.V. infusions for infants on the hospital's inpatient unit. The nurse-manager should: 1. develop an I.V. team with expertise in starting infant infusions. 2. provide nursing staff with in-service education about I.V. infusions. 3. obtain data about the types and frequency of infiltrations involved to conduct further study. 4. develop a policy for restarting all I.V. sites after 72 hours of infusion therapy.
3. obtain data about the types and frequency of infiltrations involved to conduct further study. RATIONALE: The nurse must obtain more information about the problem before implementing a change intended to improve performance on the unit. Developing an I.V. team, providing in-service education, and establishing a policy of restarting I.V. sites after 72 hours of infusion therapy aren't the best actions at this time.
Most oral pediatric medications are administered: 1. with the nighttime formula. 2. ½ hour after meals. 3. on an empty stomach. 4. with meals.
3. on an empty stomach. RATIONALE: Most oral pediatric medications are administered on an empty stomach. They aren't usually administered with milk or formula because these can affect gastric pH and alter drug absorption. Because a child's meals usually contain milk or a milk product, the nurse wouldn't administer the drugs with meals or even ½ hour after meals.
Which of the following complications is possible with an episiotomy? 1. blood loss 2. uterine disfigurement 3. prolonged dyspareunia 4. hormonal flucuation postpartum
3. prolonged dyspareunia - painful intercourse may result when complications such as infection interefere with wound healing. minimal blood loss occurs when an episitomy is done the uterus isnt affected bc its the perineum that's cut to accomodate the fetus hormonal fluctuations that occur during the postpartum period arent the result of an episiotomy
After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? 1. hypoglycemia 2. jitteriness 3. resp depression 4. tachycardia
3. resp depression mag sulfate crosses the placenta and adverse neonatal effects are: resp depression hypotonia bradycardia the serum blood sugar isnt affected by mag sulfate the neonate wold be floppy, not jittery
A nurse is planning a health teaching session for a group of parents with toddlers. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit: 1. consistent table manners. 2. an increased appetite. 3. strong food preferences. 4. a preference for eating alone.
3. strong food preferences. RATIONALE: A toddler can't be expected to use consistent table manners and, generally, the appetite decreases during the toddler stage because of a slowed growth rate. A toddler typically enjoys socializing during meals and commonly imitates others.
Which of the following rationales best explains why a pregnant client should lie on her left side when resting or sleeping in the later stages of pregnancy? 1. to facilitate digestion 2. to facilitate bladder emptying 3. to prevent compression of vena cava 4. to avoid fetal anomalies
3. to prevent compression of vena cava the weight of the preg uterus is sufficiently heavy to compress the vena cava, which could impair blood flow to the uterus, possibily decreasing oxygen to the fetus. The side lying position hasnt been shown to prevent fetal anolmaies nor bladder emptying and or digestion
A nurse observes a play group of 2-year-old children. The nurse expects to see: 1. four children playing dodgeball. 2. three children playing tag. 3. two children side by side in the sandbox building sand castles. 4. one child playing with clay and another child using flash cards.
3. two children side by side in the sandbox building sand castles. RATIONALE: Two-year-olds exhibit parallel play; that is, they engage in similar activity, side by side. Playing dodgeball and tag are examples of interactive play, common to school-age children. Playing with clay and using flash cards are behaviors seen in preschool children.
A 21y.o. client has been diagnosed with hydatidiform mole. Which of the following factors is considered a risk factor for developing hydatidiform mole? 1. age in 20s or 30s 2. high in SES 3. Primigravida 4. prior molar gestation
4. previous molar gestation increases risk for developing subsequent molar gestation by 4-5 times. Adolescents and women ages 40+ are at increased risk for molar pregs. MULTIGRAVIDAS, esp women with prior preg loss, and women with LOWER SES are at increased risk for this problem.
A client with a fractured right femur has not had any immunizations since childhood. Which of the following biologic products should the nurse administer to provide the client with passive immunity for tetanus? 1. Tetanus toxoid. 2. Tetanus antigen. 3. Tetanus vaccine. 4. Tetanus antitoxin.
4. Passive immunity for tetanus is provided in the form of tetanus antitoxin or tetanus immune globulin. An antitoxin is an antibody to the toxin of an organism. Administering tetanus toxoid, antigen, or vaccine would provide active immunity by stimulating the body to produce its own antibodies.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching? 1. To align injured bones. 2. To provide long-term pull. 3. To apply 25 lb of traction. 4. To pull weight with a boot.
4. Skeletal traction is not used to pull weight with a boot. Skeletal traction involves the insertion of a wire or a pin into the bone to maintain a pull of 5 to 45 lb on the area, promoting proper alignment of the fractured bones over a long term.
A child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask: 1. "Do you have any problems seeing different colors?" 2. "Do you have trouble seeing at night?" 3. "Do you have problems with glare?" 4. "How are you doing in school?"
4. "How are you doing in school?" RATIONALE: The nurse should ask about school because a child's poor progress in school may indicate a visual disturbance. Asking whether a person has problems with seeing colors, seeing at night, or glare is more appropriate when assessing vision in an elderly client.
The nurse is preparing a teaching plan for a 15-year-old adolescent who is 7 months pregnant. The nurse should reevaluate her teaching plan if she includes which teaching strategy? 1. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model 2. Initiating a teenage-parent support group with first- and second-time mothers 3. Using audiovisual aids that show discussions of feelings and skills 4. Providing age-appropriate reading materials
4. Providing age-appropriate reading materials RATIONALE: Because adolescents absorb less information through reading than through demonstration or discussion, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent. The other options engage more than one of the senses and therefore serve as effective teaching strategies.
A pediatric nurse clinician is discussing the pathophysiology related to childhood leukemia with a class of nursing students. Which statement made by a nursing student indicates a lack of understanding of the pathophysiology of this disease? 1. Normal bone marrow is replaced by blast cells 2. Red blood cell production is affected 3. the platelet count is decreased 4. the presence of a reed-sternberg cell is found on biopsy
4. Reed-sternberg Cell is found in Hodgkins
To examine an infant's thyroid gland, the nurse should place the infant in which position? 1. Prone 2. Sitting 3. Standing 4. Supine
4. Supine RATIONALE: The nurse should place the infant in the supine position on the caregiver's lap because it hyperextends the infant's neck, promoting thyroid palpation. A prone position wouldn't allow an adequate area for palpation. A sitting position is appropriate when assessing the thyroid gland of an older child or an adult. An infant can't stand, so this position is inappropriate.
A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes lowest priority? 1. A child who develops a fever during a blood transfusion 2. A child admitted from the postanesthesia care unit who has a blood-saturated surgical dressing 3. A physician waiting on the telephone to give the nurse a verbal order 4. Taking a lunch break
4. Taking a lunch break RATIONALE: Taking a lunch break takes lowest priority over child care. If the nurse is unable to delegate child care responsibilities to another nurse or nursing assistant, the nurse's lunch break needs to be rescheduled. A fever indicates an adverse reaction to the blood transfusion, and requires immediate intervention. The postsurgical child is losing blood through the surgical incision, which also requires attention. The telephone call is important for medication changes and to prevent a delay in treatment.
The nurse teaches the client that the major difference between angina and pain associated with myocardial infarction (MI) is that: A) Angina is relieved with nitroglycerin and rest. B) Angina can be fatal. C) MI pain always radiates to the left arm or jaw. D) MI pain cannot be treated.
A) Angina is relieved with nitroglycerin and rest.
Toxicity from which of the following medications may cause a client to see a green-yellow halo around lights? A) Digoxin B) Furosemide (Lasix) C) Metoprolol (Lopressor) D) Enalapril (Vasotec)
A) Digoxin One of the most common signs of digoxin toxicity is the visual disturbance known as the "green-yellow halo sign." The other medications aren't associated with such an effect.
Prevention of Hypoglycemic/Hyperglycemic episodes: 1 / 2 / 3?
(1) Eat (2) Insulin regularly (3) Snacks
Which step should a nurse take first when administering a liquid medication to an infant? 1. Hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. 2. Place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the cheek and gum. 3. Identify the infant by checking the armband. 4. Verify the physician order.
4. Verify the physician order. RATIONALE: The nurse should first verify the physician's order. Next, the nurse should make sure she has the right drug, dose, route, and time. She should then make sure she has the right client by checking the infant's armband. After these steps, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps him from spitting out the drug and reduces the risk of aspiration.
Which of the following factors would contribute to a high risk pregnancy? 1. Blood type O positive 2. first pregnancy at age 33y.o. 3. Hx of allergy to honey bee pollen 4. Hx of insulin dependent DM
4. a woman w/ a hx of diabetes has an increased risk for perinatal complications, including HTN, preeclampsia, and neonatal hypoglycemia. The age of 33 years w/out other risk factors doesn't increase risk, nor does type O positive blood or environmental allergens.
Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet
A, B, D Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease.
A child is diagnosed with Wilms' tumor. During assessment, the nurse expects to detect: 1. gross hematuria. 2. dysuria. 3. nausea and vomiting. 4. an abdominal mass.
4. an abdominal mass. RATIONALE: The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Gross hematuria is uncommon, although microscopic hematuria may be present. Dysuria isn't associated with Wilms' tumor. Nausea and vomiting are rare in children with Wilms' tumor.
A 16-year-old girl visits the clinic for the first time. She tells the nurse that she has been exposed to herpes. Initially, with primary genital or Type 2 herpes simplex, the nurse should expect the girl to have: 1. dysuria and urine retention. 2. perineal ulcers and erosions. 3. bilateral inguinal lymphadenopathy. 4. burning or tingling on vulva, perineum, or vagina.
4. burning or tingling on vulva, perineum, or vagina. RATIONALE: Genital burning and tingling is the most common initial finding with primary genital or Type 2 herpes simplex. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. Fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria, and urine retention are later findings in Type 2 herpes.
Which of the following answers best describes the stage of pregnancy in which maternal and fetal blood are exchanged? 1. conception 2. 9 weeks gestation when the fetal heart is well developed 3. 32-34 weeks gestation 3rd Trimester 4. maternal and fetal blood are never exchanged
4. maternal and fetal blood are never exchanged only nutrients and waste products are transferred across the placenta. blood exchange never occurs complications and some medical procedures can cause an exchange to occur accidentally
As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report, knowing the report's goal is to: 1. reprimand staff for their actions. 2. protect the nurse from a lawsuit. 3. place the blame on the adolescent. 4. record facts surrounding each incident.
4. record facts surrounding each incident. RATIONALE: The main goal of an incident report following an adventitious event isn't punishment for those involved in the incident. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents, to identify patterns of care problems, and to identify facts surrounding each incident. An incident report doesn't protect the nurse from a lawsuit.
A toddler has a temperature above 101° F (38.3° C). The physician orders acetaminophen (Tylenol), 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of: 1. sepsis. 2. leukocytosis. 3. anemia. 4. thrombocytopenia.
4. thrombocytopenia. RATIONALE: A child with thrombocytopenia or neutropenia shouldn't receive rectal medication because of the increased risk of infection and bleeding that may result from tissue trauma. No contraindications exist for administering rectal medication to a child with sepsis, leukocytosis, or anemia.
A physician orders an I.V. infusion of dextrose 5% in quarter-normal saline solution to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb. How many milliliters per hour should the nurse infuse of the ordered solution? Record your answer using a whole number. Answer: milliliters per hour
70 milliliters per hour RATIONALE: To perform this dosage calculation, the nurse should first convert the infant's weight to kilograms: 2.2 lb/kg = 22 lb/X kg X = 22 ÷ 2.2 X = 10 kg Next, she should multiply the infant's weight by the ordered rate: 10 kg × 7 ml/kg/hour = 70 ml/hour
The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. Absent bowel sounds D. +3 pedal pulses
A Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria
18. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient's arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may a. require administration of insulin while taking prednisone. b. develop acute hypoglycemia during the RA exacerbation. c. have rashes caused by metformin-prednisone interactions. d. need a diet higher in calories while receiving prednisone.
A Rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a complication of RA exacerbation or prednisone use. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA. Cognitive Level: Application Text Reference: pp. 1258, 1267 Nursing Process: Planning NCLEX: Physiological Integrity
36. After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.
A Rationale: Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Freezing alters the insulin molecule and should not be done. Cognitive Level: Application Text Reference: p. 1261 Nursing Process: Evaluation NCLEX: Physiological Integrity
13. Which information obtained by the nurse about a patient with colon cancer who is scheduled for external radiation therapy to the abdomen indicates a need for patient teaching? a. The patient swims a mile 5 days a week. b. The patient eats frequently during the day. c. The patient showers with Dove soap daily. d. The patient has a history of dental caries.
A Rationale: The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change the habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation.
5. When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?"
A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. Cognitive Level: Application Text Reference: pp. 1255, 1258 Nursing Process: Assessment NCLEX: Physiological Integrity
When reviewing laboratory results of an 83 year old patient with an infection, the nurse would expect to find: a. minimal leukocytosis b. decreased platelet count c. increased hemoglobin and hematocrit levels d. decreased erythrocyte sedimentation rate (ESR)
A - During an infection, an older adult may have only a minimal elevation in the total WBC count. This laboratory finding suggests a diminished bone marrow reserve of granulocytes in older adults and reflects possible impaired stimulation of hematopoiesis.
A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? 1. Cut in the skin from a kitchen knife 2. Excoriated perineal area 3. Abrasion of the skin 4. Pressure ulcer
1. Cut in the skin from a kitchen knife; A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated). Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary intention healing occurs when wound edges are not approximated because of full-thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and excoriations are injuries to the surface of the skin.
40. The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.
1. Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.
When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is: 1. Well approximated, with minimal or no drainage. 2. Going to take a little longer than usual to heal. 3. Going to have more scarring than most incisions. 4. Draining some serosanguineous drainage.
1. Well approximated, with minimal or no drainage; Primary intention means that the wound edges are well approximated, with minimal or no tissue loss as well as formation of minimal granulation tissue and scarring.
what would nurse emphasize when teaching the client and family about measures to prevent reinfecting and the transmission of parasitic infection
1.) wash hands before preparing food 2.) disinfect toiled 3.) bathe daily 4.) disinfect the bathtub or shower immediately after bathing 5.) avoid putting fingers in the mouth or biting fingernails.
When does regular insulin peak?
2 - 5 hours
A nurse is caring for a toddler who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report: 1. pain at the injection site. 2. generalized urticaria. 3. mild temperature elevation. 4. local swelling at the injection site.
2. generalized urticaria. RATIONALE: The nurse should instruct parents to immediately report generalized urticaria because it can herald the onset of a life-threatening episode. A child may experience some pain, redness at the sight, localized swelling, or mild temperature elevation; however, these reactions can be treated symptomatically and aren't life-threatening.
The best way for a nurse to assess pain in an 18-month-old child is to: 1. check the child's pupils. 2. observe for behavioral changes. 3. ask the child, "Are you feeling any pain?" 4. tell the parents to call if the child has pain.
2. observe for behavioral changes. RATIONALE: Behavioral changes are common signs of pain and are especially valuable indicators in an 18-month-old child, who has limited verbal skills. Evaluating pupillary response isn't an appropriate technique for assessing pain. Requesting a parental report of a child's pain isn't a reliable assessment technique.
A bottle-fed infant, age 3 months, is brought to the pediatrician's office for a well-child visit. During the previous visit, the nurse taught the mother about infant nutritional needs. Which statement by the mother during the current visit indicates effective teaching? 1. "I started the baby on cereals and fruits because he wasn't sleeping through the night." 2. "I started putting cereal in the bottle with formula because the baby kept spitting it out." 3. "I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated." 4. "I'm giving the baby skim milk because he was getting so chubby."
3. "I'm giving the baby iron-fortified formula and a fluoride supplement because our water isn't fluoridated." RATIONALE: Iron-fortified formula supplies all the nutrients an infant needs during the first 6 months; however, fluoride supplementation is necessary if the local water supply isn't fluoridated. Before age 6 months, solid foods such as cereals aren't recommended because the GI tract tolerates them poorly. Also, a strong extrusion reflex causes the infant to push food out of the mouth. Mixing solid foods in a bottle with liquids deprives the infant of experiencing new tastes and textures and may interfere with development of proper chewing. Skim milk doesn't provide sufficient fat for an infant's growth.
After a nurse explains dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching? 1. "We'll follow these instructions until our child's symptoms disappear." 2. "Our child must maintain these dietary restrictions until adulthood." 3. "Our child must maintain these dietary restrictions for life." 4. "We'll follow these instructions until our child has completely grown and developed."
3. "Our child must maintain these dietary restrictions for life." RATIONALE: Teaching is effective if the parents say their child must maintain the dietary restrictions for life because the child needs to avoid recurrence of the disease's clinical manifestations. Signs and symptoms will reappear if the client eats prohibited foods later in life.
A nurse is providing dietary teaching for the parents of a child with celiac disease. Which statement by the parents indicates effective teaching? 1. "Our child should avoid eating vegetables." 2. "Our child should avoid eating fruits." 3. "Our child should avoid eating prepared puddings." 4. "Our child should avoid eating rice."
3. "Our child should avoid eating prepared puddings." RATIONALE: Teaching is effective if the parents identify prepared puddings as a food their child should avoid. A child with celiac disease mustn't consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other options don't contain gluten and are permitted on a gluten-free diet.
A physician orders meperidine (Demerol), 30 mg I.M., as preoperative medication for a school-age child who weighs 66 lb (30 kg). The meperidine is supplied as 50 mg/ml. How much meperidine should the nurse administer? 1. 0.3 ml 2. 0.5 ml 3. 0.6 ml 4. 0.8 ml
3. 0.6 ml RATIONALE: By using the fraction method and cross-multiplying to solve for X, the nurse can determine that 0.6 ml should be administered: X ml/30 mg = 1 ml/50 mg X ml × 50 mg = 30 mg × 1 ml X = 0.6 ml.
A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable? 1. 50 mg every 6 hours 2. 100 mg every 6 hours 3. 250 mg every 6 hours 4. 500 mg every 6 hours
3. 250 mg every 6 hours RATIONALE: First, the nurse determines the minimum dose: 50 mg × 10 kg = 500 mg/day 500 mg/4 doses (for administration every 6 hours) = 125 mg/dose. Next, the nurse determines the maximum dose: 100 mg × 10 kg = 1,000 mg/day 1,000 mg/4 doses = 250 mg/dose. Thus, the acceptable dosage range for this client is 125 to 250 mg every 6 hours.
A nurse is assessing an I.V. in an infant. Which assessment finding is considered normal? 1. Erythema and pain 2. Edema 3. A lack of blood return 4. Blanching or streaking along the vein
3. A lack of blood return RATIONALE: Infants and children have small, fragile veins, making a lack of a blood return normal. Erythema, pain, edema at the site or around it, blanching, and streaking are signs of infiltration. The infusion should be discontinued immediately if any of these signs are observed
A child with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the child's history, the nurse considers which information to be most important? 1. A fever that started 3 days ago 2. Lack of interest in food 3. A recent episode of pharyngitis 4. Vomiting for 2 days
3. A recent episode of pharyngitis RATIONALE: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings aren't specific to rheumatic fever.
For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority? 1. Restricting oral intake 2. Monitoring acid-base balance 3. Avoiding abdominal palpation 4. Maintaining strict isolation
3. Avoiding abdominal palpation RATIONALE: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.
When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse? 1. Carotid artery 2. Femoral artery 3. Brachial artery 4. Radial artery
3. Brachial artery RATIONALE: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heart beat.
A nurse is caring for a client who has HIV and has been newly diagnosed with Burkitt's lymphoma. Which of the following HIV infection stages is the client in? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
A. INCORRECT: In stage 1, there are no defining conditions. B. INCORRECT: In stage 2, there are no defining conditions. C. CORRECT: In stage 3, there are one or more defining conditions present. These can include candidiasis of the esophagus, bronchi, trachea, or lungs; chronic ulcers of herpes simplex; HIV‑related encephalopathy; disseminated or extrapulmonary histoplasmosis; Kaposi's sarcoma; and Burkitt's lymphoma. D. INCORRECT: In stage 4, there is no information available.
Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation
ANS: A The current Center for Disease Control (CDC) policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay
ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.
The nurse is reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.6 mg/dL b. Serum potassium of 3.8 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 98 mg/dL
ANS: A The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time? a. Oral acyclovir (Zovirax) b. Oral saquinavir (Invirase) c. Nystatin (Mycostatin) tablet d. Aerosolized pentamidine (NebuPent)
ANS: B It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).
ANS: B The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.
Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? a. 108/64 mm Hg b. 128/76 mm Hg c. 140/90 mm Hg d. 136/ 82 mm Hg
ANS: B The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 200 mL less than the fluid intake. b. The patient is unable to move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a severe headache with pain at level 8/10 (0 to 10 scale).
ANS: B The patient's inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations also likely are caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.
The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks wine with dinner once a week
ANS: B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of an acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." d. "The patient will develop symptomatic chronic HIV infection in less than a year."
ANS: C Development of PCP meets the diagnostic criterion for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.
Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Dietary sodium restriction will control BP for most patients. b. Most patients are able to control BP through lifestyle changes. c. Hypertension is usually asymptomatic until significant organ damage occurs. d. Annual BP checks are needed to monitor treatment effectiveness.
ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes and sodium restriction are used to help manage blood pressure, but drugs are needed for most patients. BP should be checked by the health care provider every 3 to 6 months.
After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take? a. Encourage oral fluids to prevent dry mouth or dehydration. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.
ANS: C Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible side effects of other antihypertensives.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be most appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Advise the patient that this is probably the flu. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.
ANS: C Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Applying ice to the neck may provide comfort, but the initial action is to reassure the patient this is an expected finding. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu.
The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication prior to meals 2. Monitor the client's serum albumin levels 3. Assess for signs and symptoms of infection 4. Provide skin care to irradiated areas
Answer: 2 1. The nurse should administer an antiemetic prior to meals, not an antidiarrheal medication 2. Serum albumin is a measure of the protein content in the blood that is derived from food eaten; albumin monitors nutritional status 3. Assessment of the nutritional status is indicated for this problem, not assessment of the s/sx of infections. 4. This addresses an altered skin integrity problem
6) Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend? A. A bland, low-fiber diet B. A high-protein, high-calorie diet C. A diet high in fresh fruits and vegetables D. A diet emphasizing whole and organic foods
Answer: A - A bland, low-fiber diet
After a client is admitted to the pediatric unit with a diagnosis of acute lymphocytic leukemia, the laboratory test indicates that the client is neutropenic. The nurse should perform which of the following? A. advise the client to rest and avoid exertion B. prevent client exposure of infections C. monitor the blood pressure frequently D. observe for increased bruising
Answer: B Rationale: Neutropenia is a decreased number of neutrophil cells in the blood which are responsible for the body's defense against infection. Rest and avoid exertion would be related to erythrocytes and oxygen carrying properties. Monitoring the blood pressure, and observing for bruising would be related to platelets and sign and symptoms of bleeding. Objective: Describe the major types of leukemia and the most common treatment modalities and nursing interventions.
In educating a client, what would the nurse NOT mention as a risk factor that increases the risk of developing endometrial cancer? A. Obesity B. Increased age C. Having had several children D. Diabetes
Answer: C. Having had several children.
For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? A. Heart rate 52 beats/min B. Blood pressure 192/102 mm Hg C. Report of constipation D. Anxiety
B Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.
33. A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.
B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately. Cognitive Level: Application Text Reference: p. 1266 Nursing Process: Assessment NCLEX: Physiological Integrity
A 30-year-old patient has undergone a splenectomy as a result of injuries suffered in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen (select all that apply)? a. impaired fibrinolysis b. increased platelet levels c. increased eosinophil levels d. fatigue and cold intolerance e. impaired immunologic function
B, E - Splenectomy can result in increased platelet levels and impaired immunologic function as a consequence of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen.
The nursing management of a patient in sickle cell crisis includes: A. Blood transfusions and iron replacement B. Aggressive analgesic and oxygen therapy C. Platelet administration and monitoring of CBC D. Bedrest and heparin therapy
B. Aggressive analgesic and oxygen therapy
The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? A. Alopecia B. Allergy C. Fever D. Chills
B. Allergy Allergy is the most common side effect of monoclonal antibody therapy (rituximab). Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A. Morphine B. Ondansetron (Zofran) C. Naloxone (Narcan) D. Diazepam (Valium)
B. Ondansetron (Zofran) Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Morphine is a narcotic analgesic or opiate; it may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only; lorazepam, another benzodiazepine, may be used for nausea.
Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Potential for injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction
B. Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.
A 25-year-old male patient has been diagnosed with HIV. The patient does not want to take more than one antiretroviral drug. What reasons can the nurse tell the patient about for taking more than one drug? A. Together they will cure HIV. B. Viral replication will be inhibited. C. They will decrease CD4+ T cell counts. D. It will prevent interaction with other drugs
B. Viral replication will be inhibited. The major advantage of using several classes of antiretroviral drugs is that viral replication can be inhibited in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance that is a major problem with monotherapy. Combination therapy also delays disease progression and decreases HIV symptoms and opportunistic diseases. HIV cannot be cured. CD4+ T cell counts increase with therapy. There are dangerous interactions with many antiretroviral drugs and other commonly used drugs.
The nurses administering acetaminophen to a client with diabetes which is most important to monitor
Blood glucose levels
Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following? A. 120/ 90 mm Hg. B. 130/ 85 mm Hg. C. 140/ 90 mm Hg. D. 160/ 80 mm Hg.
C American Heart Association standards define hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg.
Which of the following does the nurse recognize as a contributing factor to high BP? A. decreased CO B. pulse rate of 100 C. increased afterload D. decreased stroke volume
C Increased afterload=increased PVR and BP = CO x PVR so if PVR increases then BP increases
What is the frequency of contractions in the latent stage? A. 2- 5 min, 45 -60 seconds B. 1-2 min, 60-90 seconds C. 5-10 min, 30-45 seconds D. 3-25 min, 90 seconds
C. 5-10 min, 30-45 seconds
In a severely anemic patient, the nurse would expect to find: A. Cardiomegaly and pulmonary fibrosis B. Ventricular dysrhythmias and wheezing C. Dyspnea and tachycardia D. Cyanosis and pulmonary edema
C. Dyspnea and tachycardia
Decreased AFP levels are suggested of what? A. sickle cell B. Duchenne muscular dystrophy C. down syndrome D.PKU
C. down syndrome
Nursing considerations related to the administration of chemotherapeutic drugs include which of the following? A. Anaphylaxis cannot occur, since the drugs are considered toxic to normal cells. B. Infiltration will not occur unless superficial veins are used for the intravenous infusion. C. Many chemotherapeutic agents are vesicants that can cause severe cellular damage if drug infiltrates. D. Good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary."
Correct: C. Chemotherapeutic agents can be extremely damaging to cells. Nurses experienced with the administration of vesicant drugs should be responsible for giving these drugs and be prepared to treat extravasations if necessary. 1. Anaphylaxis is a possibility with some chemotherapeutic and immunologic agents. 2. Infiltration and extravasations are always a risk, especially with peripheral veins. 4. Gloves are worn to protect the nurse when handling the drugs, and the hands should be thoroughly washed afterward.
Which of the following types of angina is most closely related with an impending MI? A) Angina decubitus B) Chronic stable angina C) Noctural angina D) Unstable angina
D) Unstable angina Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months.
The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg
D, E, F Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.
The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? (Select all that apply.) A. Heavy menses B. Smooth facial skin C. Hyperkalemia D. Breast tenderness E. Weight loss F. Deep vein thrombosis
D, F Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur. Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, is typical. Fluid retention with weight gain may also occur.
Original Alphabetical The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult client indicates understanding of the nurse's instructions? A. "Cigarette smoking always causes lung cancer." B. "Taking multivitamins will prevent me from developing cancer." C. "If I have only one shot of whiskey a day, I probably will not develop cancer." D. "I need to report the pain going down my legs to my health care provider."
D. "I need to report the pain going down my legs to my health care provider." Pain in the back of the legs could indicate prostate cancer in an older man. Cigarette smoking is implicated in causing lung cancer and other types of cancer, but it does not always cause cancer. Investigation is ongoing about the efficacy of vitamins A and C in cancer prevention. Limiting alcohol to one drink per day is only one preventive measure.
A diagnostic test use to predict neural tube defects, threatened abortion, fetal distress: A. Amniocentesis B. Chorionic villus sampling C. ultrasound D. AFP
D. AFP
A client has a glioblastoma. The nurse begins to plan care for this client with which type of cancer? A. Liver B. Smooth muscle C. Fatty tissue D. Brain .
D. Brain The prefix "glio-" is used when cancers of the brain are named. The prefix "hepato-" is included when cancers of the liver are named. The prefix "leiomyo-" is included when cancers of smooth muscle are named. The prefix "lipo-" is included when cancers of fat or adipose tissue are named
What is the test used to diagnose for fetal karyotype, sickle-cell anemia, PKU, Down Syndrome, Duchenne muscular dystrophy? A. Amniocentesis B. AFP C.Non-Stress test D. Chorionic villus sampling
D. Chorionic villus sampling
Which type of cancer has been associated with Down syndrome? A. Breast cancer B. Colorectal cancer C. Malignant melanoma D. Leukemia
D. Leukemia Leukemia is associated with Down syndrome and Turner syndrome. Breast cancer is often found clustered in families, not in association with Down syndrome. Colorectal cancer is associated with familial polyposis. Malignant melanoma is associated with familial clustering and sun exposure.
_____ or Glycosylated Hemoglobin blood test, gives an average of what your blood sugar has been over the past ____ _______.
HB A1c / 3 months
A practitioner orders a wound to be packed with a wet-to-damp gauze dressing. What should the nurse explain to the client is the primary reason for this type of dressing?
Packing the wound with wet-to-damp dressings allows epidermal cells to migrate more rapidly across the bed of the wound surface than dry dressings, thereby facilitating healing. Wet-to-damp dressings will also wick exudate up and away from the base of the wound and help to increase resistance to a wound infection.
When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply)? a) Exercise b) Allergies c) Emotional stress d) Decreased humidity e) Upper respiratory infections
a, b, c, e) Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychologic factors, and gastroesophageal reflux disease (GERD).
A client is to be discharged home with a transdermal nitroglycerin patch. Which instruction will the nurse include in the client's teaching plan? a. "Apply the patch to a nonhairy area of the upper torso or arm." b. "Apply the patch to the same site each day." c. "If you have a headache, remove the patch for 4 hours and then reapply." d. "If you have chest pain, apply a second patch next to the first patch."
a. "Apply the patch to a nonhairy area of the upper torso or arm."
A client is taking enoxaparin (Lovenox) daily. Which client statement requires additional monitoring? a. "I take aspirin daily for headaches." b. "I take ibuprofen (Motrin) at least once a week for joint pain." c. "Whenever I have a fever, I take acetaminophen (Tylenol)." d. "I take my medicine first thing in the morning."
a. "I take aspirin daily for headaches."
The nurse knows that the client's cholesterol level should be within which range? a. 150 to 200 mg/dL b. 200 to 225 mg/dL c. 225 to 250 mg/dL d. Greater than 250 mg/dL
a. 150 to 200 mg/dL
A client is prescribed enoxaparin (Lovenox). The nurse knows that low-molecular-weight heparin (LMWH) has what kind of half-life? a. A longer half-life than heparin b. A shorter half-life than heparin c. The same half-life as heparin d. A four-times shorter half-life than heparin
a. A longer half-life than heparin
The client has an international normalized ratio (INR) value of 1.5. What action will the nurse take? a. Administer an additional dose of warfarin (Coumadin). b. Hold the next dose of warfarin (Coumadin). c. Increase the heparin drip rate. d. Administer protamine sulfate.
a. Administer an additional dose of warfarin (Coumadin).
The nurse acknowledges that which condition could occur when taking furosemide? a. Hypokalemia b. Hyperkalemia c. Hypoglycemia d. Hypermagnesemia
a. Hypokalemia
The nurse would question an order for cholestyramine (Questran) if the client has which condition? a. Impaction b. Glaucoma c. Hepatic disease d. Renal disease
a. Impaction
The client is also taking a diuretic that decreases her potassium level. The nurse expects that a low potassium level (hypokalemia) could have what effect on the digoxin? a. Increase the serum digoxin sensitivity level b. Decrease the serum digoxin sensitivity level c. Not have any effect on the serum digoxin sensitivity level d. Cause a low average serum digoxin sensitivity level
a. Increase the serum digoxin sensitivity level
The client asks the nurse why the health care provider prescribed acetazolamide (Diamox), a diuretic, to treat gout. What is the nurse's best response? a. It causes an alkaline urine, which facilitates the elimination of uric acid. b. It increases alkalinity of urine, thus decreasing the formation of uric acid. c. It causes an acid urine, which facilitates the elimination of uric acid. d. It decreases alkalinity of urine, thus decreasing the formation of uric acid.
a. It causes an alkaline urine, which facilitates the elimination of uric acid.
Which assessment finding will alert the nurse to suspect early digitalis toxicity? a. Loss of appetite with slight bradycardia b. Blood pressure 90/60 mm Hg c. Heart rate 110 beats per minute d. Confusion and diarrhea
a. Loss of appetite with slight bradycardia
What intervention is essential before the nurse administers tenecteplase (TNKase)? a. Perform all necessary venipunctures. b. Administer aminocaproic acid (Amicar). c. Have the client void. d. Assess for allergies to iodine.
a. Perform all necessary venipunctures.
A client is diagnosed with peripheral arterial disease (PAD). He is prescribed isoxsuprine (Vasodilan). The nurse acknowledges that isoxsuprine does what? (Select all that apply.) a. Relaxes the arterial walls within the skeletal muscles b. May cause hypotension, chest pain, and palpitations c. Increases the rigidity of arteriosclerotic blood vessels d. May increase intermittent claudication e. May lead to hypertension and bradycardia f. Commonly causes an adverse effect of rhabdomyolysis
a. Relaxes the arterial walls within the skeletal muscles b. May cause hypotension, chest pain, and palpitations
The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after what occurs? a) Hypertension and pulmonary edema b) Oropharyngeal candidiasis and hoarseness c) Elevation of blood glucose and calcium levels d) Adrenocortical dysfunction and hyperglycemia
b) Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.
The client asks the nurse how nitroglycerin should be stored while traveling. What is the nurse's best response? a. "You can protect it from heat by placing the bottle in an ice chest." b. "It's best to keep it in its original container away from heat and light." c. "You can put a few tablets in a resealable bag and carry it in your pocket." d. "It's best to lock them in the glove compartment to keep them away from heat and light."
b. "It's best to keep it in its original container away from heat and light."
The nurse is reviewing instructions for a client taking an HMG-CoA reductase inhibitor (statin). What information is essential for the nurse to include? a. "Take this medication on an empty stomach." b. "Take this medication at the same time each day." c. "Take this medication with breakfast." d. "Take this medication with an antacid."
b. "Take this medication at the same time each day."
A client is receiving an intravenous heparin drip. Which laboratory value will require immediate action by the nurse? a. Platelet count of 150,000 b. Activated partial thromboplastin time (aPTT) of 120 seconds c. INR of 1.0 d. Blood urea nitrogen (BUN) level of 12 mg/dL
b. Activated partial thromboplastin time (aPTT) of 120 seconds
A client who has been taking warfarin (Coumadin) is admitted with coffee-ground emesis. What is the nurse's primary action? a. Administer vitamin E. b. Administer vitamin K. c. Administer protamine sulfate. d. Administer calcium gluconate.
b. Administer vitamin K.
A client is ordered furosemide (Lasix) to be given via intravenous push. What interventions should the nurse perform? (Select all that apply.) a. Administer at a rate no faster than 20 mg/min. b. Assess lung sounds before and after administration. c. Assess blood pressure before and after administration. d. Maintain accurate intake and output record. e. Monitor ECG continuously. f. Insert an arterial line for continuous blood pressure monitoring.
b. Assess lung sounds before and after administration. c. Assess blood pressure before and after administration. d. Maintain accurate intake and output record.
What must the nurse monitor when titrating intravenous nitroglycerin for a client? (Select all that apply.) a. Continuous oxygen saturation b. Continuous blood pressures c. Hourly ECGs d. Presence of chest pain e. Serum nitroglycerin levels f. Visual acuity
b. Continuous blood pressures d. Presence of chest pain
During an admission assessment, the client states that she takes amlodipine (Norvasc). The nurse wishes to determine whether or not the client has any common side effects of a calcium channel blocker. The nurse asks the client if she has which signs and symptoms? (Select all that apply.) a. Insomnia b. Dizziness c. Headache d. Angioedema e. Ankle edema f. Hacking cough
b. Dizziness c. Headache e. Ankle edema
Which laboratory value will the nurse report to the health care provider as a potential adverse response to hydrochlorothiazide (HydroDIURIL)? a. Sodium level of 140 mEq/L b. Fasting blood glucose level of 140 mg/dL c. Calcium level of 9 mg/dL d. Chloride level of 100 mEq/L
b. Fasting blood glucose level of 140 mg/dL
When a client first takes a nitrate, the nurse expects which symptom that often occurs? a. Nausea and vomiting b. Headaches c. Stomach cramps d. Irregular pulse rate
b. Headaches
The nurse is monitoring a client taking digoxin (Lanoxin) for treatment of heart failure. Which assessment finding indicates a therapeutic effect of the drug? a. Heart rate 110 beats per minute b. Heart rate 58 beats per minute c. Urinary output 40 mL/hr d. Blood pressure 90/50 mm Hg
b. Heart rate 58 beats per minute
A client's high-density lipoprotein (HDL) is 60 mg/dL. What does the nurse acknowledge concerning this level? a. It is lower than the desired level of HDL. b. It is the desired level of HDL. c. It is higher than the desired level of HDL. d. It is a much lower HDL level than desired.
b. It is the desired level of HDL.
A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in that area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen.
b. Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.
A client is prescribed a noncardioselective beta1 blocker. What nursing intervention is a priority for this client? a. Assessment of blood glucose levels b. Respiratory assessment c. Orthostatic blood pressure assessment d. Teaching about potential tachycardia
b. Respiratory assessment
The client is taking rosuvastatin (Crestor). What severe skeletal muscle adverse reaction should the nurse observe for? a. Myasthenia gravis b. Rhabdomyolysis c. Dyskinesia d. Agranulocytosis
b. Rhabdomyolysis
In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: a. Walking several times each day as an exercise program. b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation
b. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.
Which technique is considered the gold standard for diagnosing DVT? a. Ultrasound imaging b. Venography c. MRI d. Doppler flow study
b. Venography
A woman who's 36 weeks pregnant comes into the labor & delivery unit with mild contracts. Which of the following complications should the nurse watch out for when the client informs her that she has placenta prevue? a. sudden rupture of membranes b. vaginal bleeding c. emesis d. fever
b. vaginal bleeding contractions may disrupt the microvascular network in the placenta of a client with placenta prevue and result in bleeding. If the separation of the placenta occurs at the margin of the placenta, the blood will escape vaginally. Sudden rupture of the membranes isn't related to placenta prevue. Fever would indicate an infectious process, and emesis isn't related to placenta previa
A client's recently drawn serum lidocaine drug level is 3.0 mcg/mL. What is the nurse's priority intervention? a. Increase the lidocaine infusion. b. Decrease the lidocaine infusion. c. Continue to monitor the client. d. Stop the IV drip for 1 hour.
c. Continue to monitor the client.
A nurse is caring for a client taking cholestyramine (Questran). The client is complaining of constipation. What will the nurse do? a. Call the health care provider to change the medication. b. Tell the client to skip a dose of the medication. c. Have the client increase fluids and fiber in his diet. d. Administer an enema to the client.
c. Have the client increase fluids and fiber in his diet.
Which nursing diagnosis would be possible for a client receiving intravenous heparin therapy? a. Potential for fluid volume excess b. Potential for pain c. Risk for injury d. Potential for body image disturbance
c. Risk for injury
The nurse is monitoring a client during IV nitroglycerin infusion. Which assessment finding will cause the nurse to take action? a. Blood pressure 110/90 mm Hg b. Flushing c. Headache d. Chest pain
d. Chest pain
Cilostazol (Pletal) is being prescribed for a client with coronary artery disease. The nurse knows that which is the major purpose for antiplatelet drug therapy? a. To dissolve the blood clot b. To decrease tissue necrosis c. To inhibit hepatic synthesis of vitamin K d. To suppress platelet aggregation
d. To suppress platelet aggregation
DKA may be the first sign of
daibetes
Differant things you'll see with DKA - ________ insulin / ________ keytones (anion gap metabolic acidosis) / leads to __________ potasium in the cell / ofcourse the glucose is _______ with DKA leading to _____________ becuase there are tooooo many particles in the vascular space for the kidneys to push out so there is an ______ diuresis. Becuase of the kidney failure - there is an ____________ in Creatinine (and BUN?) Also, the major dehydration leads to pulling the potassium out of the cell and we have a total body potassium __________. You could also see a decrease in phosphorus with the decrease in potassium and if so could be an increase in calcium.
decreased / increased / increased / increased / dehydration / osmotic / increase / depletion
The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"
C It is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern.
A chest x-ray should a client's lungs to be clear. His Mantoux test is positive, with a 10mm if induration. His previous test was negative. These test results are possible because: A He had TB in the past and no longer has it. B He was successfully treated for TB, but skin tests always stay positive C He's a "seroconverter", meaning the TB has gotten to his bloodstream D He's a "tuberculin converter," which means he has been infected with TB since his last skin test
D)
A significant cause of venous thrombosis is: a. Altered blood coagulation b. Stasis of blood c. Vessel wall injury d. All of the above
D. All
A patient with hemophilia comes to the emergency room after bumping his knee. The knee is rapidly swelling. Which is the first nursing action? A. Initiate an IV site to begin administration of cryoprecipitate B. Type and cross-match for possible transfusion C. Draw blood for determination of hemoglobin and hematocrit values to monitor bleeding D. Apply ice pack and compression dressings to the knee
D. Apply ice pack and compression dressings to the knee
____ is probably the best source of protein for heart protection as it can help lower blood pressure, triglyceride levels, and tendency for blood clots, and the risk for stroke
Fish - remember need protein - 20 to 30 percent
Wait until the blood sugar ___________ before beginning exercise
normalizes
Should a client's bladder be full for an amniocentesis test?
no if greater than 20 weeks pregnancy
D50W is hard to ______, if you have a choice, you need a ______ bore IV
push / large
Diabetics tend to have ___________ disease
renal (this is why many are put on dialysis at home)
A recently divorced male who has undergone radiation therapy for testicular cancer tells the nurse he is unable to achieve an erection. Which of the following nursing diagnoses is most appropriate? A: Ineffective coping related to the effects of radiation therapy B: Sexual dysfunction related to the effects of radiation therapy C: Disturbed body image related to the effects of radiation therapy D: Imbalanced nutrition: Less than body requirements related to radiation therapy
Answer: B: Sexual dysfunction related to the effects of radiation therapy Rationale: Radiation may cause sexual dysfunction. Libido may only be temporarily affected, and the client should be provided with emotional support.
At a senior citizen program, the nurse who was invited to speak to the group is teaching them about detecting the early signs of cancer. Which of the following should the nurse include? A: Do not overexpose yourself to the sun B: Exercise for no more than 7 minutes a day C: Lower the amount of fats in your diet D: Do a monthly breast self-exam
Answer: D: Do a monthly breast self-exam Rationale: Monthly breast exams aid in early detection of cancer. Changing the patients diet and limiting exposure to the sun may help with prevention but not detection.
High ______ slows down ________ absorption in the intestines, so eliminating the sharp rise and fall of all blood sugar.
fiber glucose
Do not mix _______ and animal insulin
human
how long should normal acrocyanosis last max.
max 24 hours post birth
Breastfeeding preterm neonates
studies have proven that breast milk provides preterm neonates w/ better protection from infection such as NEC bc of the antibodies contained in breast milk Commercial formula doesn't provide any better nutrition than breast milk breast milk feedings can be started as soon as the neonate is stable and the neonate is more likely to develop infections when fed formula rather than breast milk
Pulmonary embolus signs
sudden dyspnea diaphoresis confusion tachycardia stationary blood clot from a varicose vein becomes an embolus (moving clot) that lodges in the pulmonary circulation chills and fever = infection
Insulin should not be left in the car or checked in airline baggage because of potential changes in _____________.
temperature
Convection heat loss
the flow of heat from the body surface to COOLER AIR
How should a nurse position a 4-month-old infant when administering an oral medication? 1. Seated in a high chair 2. Restrained flat in the crib 3. Held on the nurse's lap 4. Held in the bottle-feeding position
4. Held in the bottle-feeding position RATIONALE: The nurse 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. A 4-month-old infant can't sit unsupported in a high chair. Administering medication to an infant lying flat could cause choking and aspiration. Holding the infant in the lap may cause the medication to spill.
A nurse is helping a pregnant client devise a plan to help her 2-year-old child adjust to the birth of her second child. Which statement by the client indicates more instruction is needed? 1. "I'll give my child a doll so he can imitate us when we care for the new baby." 2. "I'll enroll my child in a sibling class. 3. "I'll discuss with my child what routines will be the same and what will be different after the baby arrives." 4. "I'll tell my child that the new baby can be a playmate when he arrives."
4. "I'll tell my child that the new baby can be a playmate when he arrives." RATIONALE: Telling a toddler that he will have a new playmate when the baby arrives sets up unrealistic expectations and, therefore, indicates the client needs more instruction. The parents should stress activities that will take place, such as feeding, changing, and crying. Giving the toddler a doll is a good strategy because having the doll allows the toddler to take part in the new routines. For example, the toddler can pretend to meet the needs of the doll just like the mother tends to the baby. Participation in a sibling preparation class may also decrease sibling rivalry behaviors. Discussing changes in family routines will help the toddler know what to expect.
A blood type and cross-match has been ordered for a male patient who is experiencing an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains what this means? a. the patient can be transfused with type AB blood. b. the patient may only receive a type A transfusion. c. the patient has A antigens on his red blood cells (RBCs). d. antibodies are present on the surface of the patient's RBCs.
C - An individual with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood.
The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? a. unit secretary b. a physician's assistant c. another registered nurse d. an unlicensed assistive personnel
C - Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.
A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate: a. hyperkalemia b. hyperuricemia c. hypercalcemia d. CNS myeloma
C - Bone degeneration in multiple myeloma causes calcium to be lost from bones, which eventually results in hypercalcemia. Hypercalcemia may cause renal, gastrointestinal, or neurologic manifestations, such as polyuria, anorexia, or confusion, and may ultimately cause seizures, coma, and cardiac problems.
A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in her left knee joint. What should be the emergency nurse's immediate response to this? a. immediate transfusion of platelets b. resting the patient's knee to prevent hemarthroses c. assistance with intracapsular injection of corticosteroids d. range-of-motion exercises to prevent thrombus formation
C - In patients with hemophilia, joint bleeding requires resting of the joint in order to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.
The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that: a. Hodgkin's lymphoma occurs only in young adults b. Hodgkin's lymphoma is considered potentially curable c. non-Hodgkin's lymphoma can manifest in multiple organs d. non-Hodgkin's lymphoma is treated only with radiation therapy
C - Non-Hodgkin's lymphoma can originate outside the lymph nodes, the method of spread can be unpredictable, and most affected patients have widely disseminated disease.
29. The nurse has identified the nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation in a patient with lung cancer who has had a 10% loss in weight. An appropriate nursing intervention that addresses the etiology of this problem is to a. provide foods that are highly spiced to stimulate the taste buds. b. avoid presenting foods for which the patient has a strong dislike. c. add strained baby meats to foods such as soups and casseroles. d. teach the patient to eat whatever is nutritious since food is tasteless.
B Rationale: The patient will eat more if disliked foods are avoided and foods that patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. Patients will not improve intake by eating foods that are beneficial but have unpleasant taste.
Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse should recognize that this diagnostic finding most likely suggests which problem? a. hypoxemia b. an infection c. a risk of hypocoagulation d. an acute thrombotic event
B - An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.
A 54-year-old patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? a. "With type 2 diabetes, the body of the pancreas becomes inflamed." b. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." c. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." d. "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."
B - In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced, and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.
The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? a. "I should only walk barefoot in nice dry weather." b. "I should look at the condition of my feet every day." c. "I am lucky my shoes fit so nice and tight because they give me firm support." d. "When I am allowed up out of bed, I should check the shower water with my toes."
B - Patients with diabetes mellitus need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Water temperature should be tested with the hands first.
The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? a. 11:45 AM b. 12:00 noon c. 12:30 PM d. 3:30 PM
B - The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.
Polydipsia and polyuria related to diabetes mellitus are primarily due to: a. the release of ketones from cells during fat metabolism b. fluid shifts resulting from the osmotic effect of hyperglycemia c. damage to the kidneys from exposure to high levels of glucose d. changes in RBCs resulting from attachment of excessive glucose to hemoglobin
B - The osmotic effect of glucose produces the manifestations of polydipsia and polyuria.
The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure? a. position the patient prone. b. apply a pressure dressing. c. administer analgesic for pain. d. return metal objects to the patient.
B - The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.
NPH is __________
cloudy
A nurse is assessing a client newly diagnosed with Stage I Hodgkin's lymphoma. Which area of the body would the nurse most likely find involved? 1. Back 2. Chest 3. Groin 4. Neck
(4. Neck is correct) At the time of diagnosis of stage I Hodgkin's lymphoma, a painless cervical lesion is often present. The back, chest, and groin areas may be involved in later stages.
What are some complications of an amniocentesis?
- premature labor - infections - amniotic embolism - Abruptio placentae - RH isoimmunization
Which assessment finding is an early sign of heart failure in a toddler? 1. Increased respiratory rate 2. Increased urine output 3. Decreased weight 4. Decreased heart rate
1. Increased respiratory rate RATIONALE: Increased respiratory and heart rates are the earliest signs of heart failure. Decreased urine output and increased weight are later signs.
A 44-lb preschooler is being treated for inflammation. The physician orders 0.2 mg/kg/day of dexamethasone (Decadron) by mouth to be administered every 6 hours. The elixir comes in a strength of 0.5 mg/5 ml. How many teaspoons of dexamethasone should the nurse give this client per dose? Record your answer using a whole number. Answer: teaspoons
2 teaspoons RATIONALE: To perform this dosage calculation, the nurse should first convert the child's weight from pounds to kilograms: 44 lb ÷ 2.2 lb/kg = 20 kg Then she should calculate the total daily dose for the child: 20 kg × 0.2 mg/kg/day = 4 mg Next, the nurse should calculate the amount to be given at each dose: 4 mg ÷ 4 doses = 1 mg/dose The available elixir contains 0.5 mg of drug per 5 ml (which is equal to 1 teaspoon). Therefore, to give 1 mg of the drug, the nurse should administer 2 teaspoons (10 ml) to the child for each dose.
For people with diabetes, the ideal goal is for their HbA1c to be _____% or ____ or ADA says:
4-6% or LESS / < 7%
3). Which clinical manifestation would the nurse expect to find in newly diagnosed intrinsic LC? 1. Dysphagia 2. Foul smelling breath 3. Hoarseness 4. Weight loss
Answer: 3- Hoarseness Rational: Hoarseness is an early sign.
All of the following disorders are caused by chromosomal alteration except? A. Klinefelter's syndrome B. BRCA-1 C. Down Syndrome D. Turner's Syndrome
B. BRCA-1
A client diagnosed with active TB would be hospitalized primarily for which of the following reasons? A To evaluate his condition B To determine his compliance C To prevent spread of the disease D To determine the need for antibiotic therapy
C) The client with active TB is highly contagious until three consecutive sputum cultures are negative, so he's put in respiratory isolation in the hospital.
A nurse is assessing a patient for essential hypertension. She will expect him to report which symptom? A. Chest tightness B. Shortness of Breath C. No symptoms to report D. Anxious
C. Primary (essential) HTN is the silent killer and s/s are not obvious
In a pt with DB Type II, the majority of the calories should come from: and how much?
Complex Carbs (55-60%), Fats (20-30%), Proteins (12-20%)
What is the term the refers to the number of pregnancies regardless of duration?
Gravida
__________________ work by stimulating the pancreas to make insulin
Hypoglycemic agents (but not all do this)
Hyperosmolar hyperglycemic nonketosis (HHNK) is usually seen in Type __ Diabetes
II
Low sugar = _____ calcium
Low
Nursing students are reviewing information about epidural pain management with opioid analgesicsThe students demonstrate an understanding whenhey identify which advantages over other following routes for administration
Lower dose of opioids Fewer adverse reaction Greater client comfort
Do not use the same site more than _____ in one month
ONCE
Glipizide (Glucotrol), Metformin (Glucophage), and Pioglitazone (Actos) are all: ONLY GIVE TO WHO?
Oral Anti-Diabetic Agents / Type II DB - NONinsulin dependant DM (NIDDM)
Which of the following hormones would be administered for the stimulation of uterine contractions? 1. Estrogen 2. Fetal cortisol 3. Oxytocin 4. Progesterone
Oxytocin is the hormone responsible for stimulating UCs. Pitocin, the synthetic form, may be given to clients who are past their due date. Progesterone has a relaxation effect on the uterus Fetal cortisol is believed to slow the production of progesterone by the placenta although estrogen has a role in UC, it isnt given in a synthetic form to help UC
After the simple sugars make the blood sugar rise, what should they follow it up with? Why?
Protein - to keep the sugar from bottoming out.
The nurse assesses client for adverse reactions which would the nurse assess
Respiratory depression constipation miosis
(Opened or Unopened) vials should be refrigerated; the other vials can be stored at room temperature
Unopened
A 60-year-old client has been administered and said that he was taking over the counter NSAID The nurse tells the client not to overuse because
Ulcer disease
A newly admitted client takes digoxin 0.25 mg/day. The nurse knows that which is the serum therapeutic range for digoxin? a. 0.1 to 1.5 ng/mL b. 0.5 to 2.0 ng/mL c. 1.0 to 2.5 ng/mL d. 2.0 to 4.0 ng/mL
b. 0.5 to 2.0 ng/mL
Which assessment finding in a client taking an HMG-CoA reductase inhibitor will the nurse act on immediately? a. Decreased hemoglobin b. Elevated liver function tests c. Elevated HDL d. Elevated LDL
b. Elevated liver function tests
The insulin dose is increased until the ___________ _______ is normal and until there are no more ________ and ________ in the urine.
blood sugar / keytones and glucose
What is chadwick's sign?
bluish color of cervix
A client is prescribed dalteparin (Fragmin). LMWH is administered via which route? a. Intravenously b. Intramuscularly c. Intradermally d. Subcutaneously
d. Subcutaneously
What does acme mean?
peak of contraction
While assessing the lymph nodes, the nurse should: a. apply gentle, firm pressure to deep lymph nodes b. palpate the deep cervical and supraclavicular nodes last c. lightly palpate superficial lymph nodes with the pads of the fingers d. use the tips of the second, third and fourth fingers to apply deep palpation
C - To assess superficial lymph nodes, the nurse should lightly palpate the nodes, using the pads of the fingers. Then the nurse gently rolls the skin over the area and concentrates on feeling for possible lymph node enlargement.
Which of the following diagnostic tests is definitive for TB? A Chest x-ray B Mantoux test C Sputum culture D Tuberculin test
C) The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis. Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or falsely negative.
Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client's history, would require physician notification? A Heart disease B Allergy to penicillin C Hepatitis B D Rheumatic fever
C) Isoniazid and rafampin are contraindicated in clients with acute liver disease or a history of hepatic injury.
A pregnant woman who was tested and diagnosed with HIV infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will probably be infected with HIV." B. "Only an abortion will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection.
C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism as well as host immune status are variables related to transmission via blood, semen, vaginal secretions, or breast milk.
Multiple drugs are often used in combinations to treat leukemia and lymphoma because: a. there are fewer toxic and side effects b. the chance that one drug will be effective is increased c. the drugs are more effective without causing side effects d. the drugs work by different mechanisms to maximize killing of malignant cells
Correct answer: D Combination therapy is the mainstay of treatment for leukemia. The three purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity to the patient by using multiple drugs with varying toxicities, and (3) interrupt cell growth at multiple points in the cell cycle.
Which of the following manifestations would be directly associated with Hodgkin's disease? a. bone pain b. generalized edema c. petechiae and purpura d. painless, enlarged lymph nodes
Correct answer: D Rationale: Hodgkin's disease usually presents as painless enlarged lymph nodes. The diagnosis is made by lymph node biopsy.
The nurse is caring for a 59-year-old woman who had surgery 1 day ago for removal of a suspected malignant abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to: a. Motivate change in unhealthy lifestyles. b. Educate her about the seven warning signs of cancer. c. Instruct her about healthy stress relief and coping practices. d. Allow her to communicate about the meaning of this experience.
Correct answer: D Rationale: While the patient is waiting for diagnostic study results, the nurse should be available to actively listen to the patient's concerns and should be skilled in techniques that can engage the patient and the family members or significant others in a discussion about their cancer-related fears.
A diagnosis of AIDS is made when an HIV-infected patient has a. a CD4+ T cell count below 200/µL. b. a high level of HIV in the blood and saliva. c. lipodystrophy with metabolic abnormalities. d. oral hairy leukoplakia, an infection caused by Epstein-Barr virus.
Correct answer: a Rationale: AIDS is diagnosed when an individual with HIV infection meets one of several criteria; one criterion is a CD4+ T cell count below 200 cells/L. Other criteria are listed in Table 15-9.
Transmission of HIV from an infected individual to another most commonly occurs as a result of a. unprotected anal or vaginal sexual intercourse. b. low levels of virus in the blood and high levels of CD4+ T cells. c. transmission from mother to infant during labor and delivery and breastfeeding. d. sharing of drug-using equipment, including needles, syringes, pipes, and straws
Correct answer: a Rationale: Unprotected sexual contact (semen, vaginal secretions, or blood) with a partner
MULTIPLE RESPONSE 1. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply.) a. Alcohol use b. Physical activity c. Body weight d. Colorectal screening e. Tobacco use f. Mammography g. Pap testing h. Sunscreen use
D, F, G, H Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
During assessment of a client diagnosed with pheochromocytoma, the nurse auscultates a blood pressure of 210/110 mm Hg. What is the nurse's best action? a. To ask the client to lie down and rest b. To assess the client?s dietary intake of sodium and fluid c. To administer phentolamine (Regitine) d. To administer nitroprusside (Nipride)
c. To administer phentolamine (Regitine)
Captopril (Capoten) has been ordered for a client. The nurse teaches the client that ACE inhibitors have which common side effects? a. Nausea and vomiting b. Dizziness and headaches c. Upset stomach d. Constant, irritating cough
d. Constant, irritating cough
Which test is considered diagnostic for Hodgkin's lymphoma? 1. A magnetic resonance image (MRI) of the chest. 2. A computed tomography (CT) scan of the cervical area. 3. An erythrocyte sedimentation rate (ESR). 4. A biopsy of the cervical lymph nodes.
Correct: 4. 1. An MRI of the chest area will determine numerous disease entities, but it cannot determine the specific morphology of Reed-Sternberg cells, which are diagnostic for Hodgkin's disease. 2. A CT scan will show tumor masses in the area, but it is not capable of pathological diagnosis. 3. ESR laboratory tests are sometimes used to monitor the progress of the treatment of Hodgkin's disease, but ESR levels can be elevated in several disease processes. 4. Cancers of all types are definitively diagnosed through biopsy procedures.The pathologist must identify Reed Sternberg cells for a diagnosis of Hodgkin's disease (correct)
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status? 1. "Can you ride a tricycle?" 2. "Can you draw your school?" 3. "Do you like your brother?" 4. "What's your mommy's first name?"
1. "Can you ride a tricycle?" RATIONALE: Asking the child if he can ride a tricycle best helps evaluate the child's developmental status because a 4-year-old child should be able to perform such an action. A child may draw stick-like figures, but wouldn't be able to draw complicated pictures such as a school. A 4-year-old child may not be aware of his feelings, so asking whether he likes his brother wouldn't be appropriate. A 4-year-old child may not know his mother's first name, so asking it wouldn't evaluate developmental status.
Which use of restraints in a school-age child should the nurse question? 1. To substitute for observation 2. To ensure the child's comfort or safety 3. To facilitate examination 4. To aid in carrying out procedures
1. To substitute for observation RATIONALE: Restraints should never be used as a punishment or as a substitute for observation because if a child is at risk for harming himself when left alone, the child requires one-on-one observation. Ensuring the child's comfort or safety (restraining him to keep an I.V., drainage tube, or orthopedic device in place), facilitating examination, and carrying out procedures are all valid reasons for restraint. Restraining devices aren't without risk and must be checked and documented every 1 to 2 hours.
the nurse is preparing to administer an antiviral drug to a client. which include in preadministration
1.) Clients general state of health 2.) Resistance to infection 3.)Vitals signs
A child, age 4, fell and broke his arm and had a cast applied. Which of these statements by the child indicates an immediate risk for compartment syndrome? 1. "My arm hurts." 2. "I can't wiggle my fingers." 3. "I need to go home." 4. "Don't touch me."
2. "I can't wiggle my fingers." RATIONALE: Signs and symptoms of compartment syndrome, such as motor weakness, reflect a deficit or deterioration of neuromuscular status in the involved area. Inability to wiggle fingers indicates an immediate risk for compartment syndrome because it could suggest neurovascular pressure or damage caused by edema following the injury. The other statements don't indicate risk for compartment syndrome.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur? 1. 1 to 2 years 2. 1 week to 1 year, peaking at 2 to 4 months 3. 6 months to 1 year, peaking at 10 months 4. 6 to 8 weeks
2. 1 week to 1 year, peaking at 2 to 4 months RATIONALE: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.
A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first? 1. Call the physician caring for the child. 2. Ease the child to the floor and turn him on his side. 3. Administer diazepam (Valium) through the I.V. tubing. 4. Notify the parents so they can be with their child.
2. Ease the child to the floor and turn him on his side. RATIONALE: Because the child is standing, he should first be eased to the floor and turned to the side to prevent aspiration. Notifying the physician wouldn't be the first action the nurse would take because the child's safety is of primary importance. Diazepam would be administered only if it had been ordered. Notifying the parents, although important, isn't the priority. They can be informed after the seizure is over.
When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about? 1. Post surgical hemorrhage and anemia 2. Wound dehiscence and evisceration 3. Impaired skin integrity and decubitus ulcers 4. Loss of motility and paralytic illeus
2. Wound dehiscence and evisceration; Wound dehiscence is most likely to occur 4 to 5 days postoperatively, and risk factors include obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration.
A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G
3. 23G RATIONALE: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate. An 18G or 20G needle is too large, and the 27G needle too small.
Which nursing ntervention helps prevent evaporative heat loss in the neonate immed after birth? 1. admin warm oxygen 2. controlling drafts in the room 3. immed drying the neonate 4. placing neonate on a warm, dry towel
3. immed drying the neonate decreases evaoporative heat loss from moist body from birth placing the neonate on a warm, dry towel decreases CONDUCTIVE losses. controlling draft in the room and admin warm oxygen helps reduce CONVECTIVE LOSS
After a series of tests, a 6-year-old client weighing 50 lb (22.7 kg) is diagnosed with complex partial seizures. The physician orders phenytoin (Dilantin), 125 mg by mouth twice per day. After the nurse administers phenytoin, where is the drug metabolized? 1. Pancreas 2. Kidneys 3. Stomach 4. Liver
4. Liver RATIONALE: Phenytoin is metabolized in the liver. The pancreas isn't involved in the pharmacokinetic activity of phenytoin. The stomach absorbs orally administered phenytoin, which is excreted by the kidneys in the urine.
You are at the scene of an accident and find the victim has a bleeding lower leg wound. After flushing the wound with water and covering it with a clean dressing, you find the dressing has been saturated with blood. Which of the following would be the best action to take in this case? 1. Lower the extremity while applying pressure to the wound. 2. Take off the first dressing and apply another clean or sterile dressing. 3. Encircle the client's ankle with your hands and apply pressure. 4. Reinforce the first layer of dressing with a second layer of dressing.
4. Reinforce the first layer of dressing with a second layer of dressing; To control severe bleeding, apply direct pressure to the wound and elevate the extremity. If the dressing becomes saturated, apply a second layer. Removing the first dressing may disturb blood clots and increase the bleeding.
A 9-year-old boy with diabetes mellitus tests his glucose level in the nurse's office before lunch. According to this sliding scale of insulin, he's due for 1 unit of regular insulin. What steps should a nurse follow after confirming the medication order, washing her hands, drawing up the appropriate dose, verifying the boy's identity, and putting on gloves? Put the following steps in chronological order. 1. Pinch the skin around the injection site 2. Release the skin and give the injection. 3. Clean site with an alcohol pad; loosen needle cover. 4. Select appropriate injection site with the child. 5. Cover the site with an alcohol pad. 6. Uncover needle; insert at 45- to 90- degree angle.
4. Select appropriate injection site with the child. 3. Clean site with an alcohol pad; loosen needle cover. 1. Pinch the skin around the injection site 6. Uncover needle; insert at 45- to 90- degree angle. 2. Release the skin and give the injection. 5. Cover the site with an alcohol pad. RATIONALE: To give a subcutaneous injection of insulin to a child, the nurse should first select an appropriate injection site, being sure to discuss the selection with the child to ensure that injection sites are rotated. She should then clean the injection site with an alcohol pad and loosen the needle cover. The next step is to pinch the skin around the site. She should then uncover the needle and insert the needle at a 45- to 90-degree angle, release the skin, and give the injection. When finished, the nurse should cover the injection site with an alcohol pad and avoid rubbing the site.
A 3-year-old child is to receive 500 ml of dextrose 5% in normal saline solution over 8 hours. At what rate (in milliliters/hour) should the nurse set the infusion pump? Record your answer using one decimal place. Answer: milliliters/hour
62.5 milliliters/hour RATIONALE: To calculate the rate per hour for the infusion, the nurse should divide 500 ml by 8 hours: 500 ml ÷ 8 hours = 62.5 ml/hour.
The nurse is assigned to all of these clients. Which client should be assessed first? A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot
A The client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.
The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? a. cheese b. broccoli c. chicken d. oranges
A - Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.
The patient has anemia and has had laboratory tests done to diagnose the cause. Which results should the nurse know indicates a lack of nutrients needed to produce new red blood cells (select all that apply)? a. increased homocysteine b. decreased reticulocyte count c. decreased cobalamin (vitamin B12) d. increased methylmalonic acid (MMA) e. elevated erythrocyte sedimentation rate (ESR)
A, C, D - Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.
Appropriate nursing actions when caring for a hospitalized patient with severe neutropenia include: A. Strict handwashing and frequent vital sign assessment B. Monitoring lung sounds and invasive blood pressures C. Oral care and red blood cell administration D. Perirectal care and platelet administration
A. Strict handwashing and frequent vital sign assessment
The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? A. Testing of stool specimens for occult blood B. Teaching about the importance of dietary fiber C. Referring clients for colonoscopy procedures D. Giving vitamin and mineral supplements
A. Testing of stool specimens for occult blood Testing of stool specimens for occult blood is done according to a standardized protocol and can be delegated to nursing assistants. Client education is within the scope of practice of the RN, not of the LPN or nursing assistant. Referral for further care is best performed by the RN. Administration of medications is beyond the nursing assistant's scope of practice and should be done by licensed nursing personnel.
The RN is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which of the following nursing actions can the nurse delegate to an experienced LPN/LVN? a. Titrate nitroprusside to maintain BP at 160/100 mm Hg. b. Evaluate effectiveness of nitroprusside therapy on BP. c. Set up the automatic blood pressure machine to take BP every 15 minutes. d. Assess the patient's environment for adverse stimuli that might increase BP.
ANS: C LPN/LVN education and scope of practice include correct use of common equipment such as automatic blood pressure machines. The other actions require more nursing judgment and education and should be done by RNs.
A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of 188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. the dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. more diagnostic testing may be needed to determine the cause of the hypertension.
ANS: D A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.
A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. Which of the following is the appropriate and supportive response to the mother? 1. I'm not sure. I'll discuss it with the physician. 2. The child is too young to have radiation therapy. 3. It's very costly, and chemotherapy works just as well. 4. The physician would prefer that you discuss the treatment options with the oncologist.
ANSWER: 2 Rationale: Radiation therapy is usually delayed until a child is 8 years of age, if possible, to prevent retardation of bone growth and soft tissue development. Options 1,3, and 4 are inappropriate responses to the mother.
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? "a. "Have you noticed a change in sleeping habits recently?" b. "Have you had a respiratory infection in the last 6 months?" c. "Have you lost weight recently?" d. "Have you noticed changes in your alertness?"
Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? a. Body temperature of 99°F or less b. Toes moved in active range of motion c. Sensation reported when soles of feet are touched d. Capillary refill of < 3 seconds
Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
9). A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate? 1. "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size." 2. "Annual x-rays will increase your risk for cancer because of exposure to radiation." 3. "Insurance companies do not authorize yearly x-rays just to detect early lung cancer." 4. "Frequent x-rays damage the lungs and make them more susceptible to cancer."
Answer: 1-"Chest x-rays do not detect cancer until tumors are already at least a half-inch in size." Rational: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.
The community health nurse is instructing a group of young female clients bout breast self-examination. The nurse should instruct the clients to perform the examination at which time? A. At the onset of menstruation B. Every month during ovulation C. Weekly at the same time of day D. 1 week after menstruation begins
Answer: D Rationale: The breast self-examination should be performed monthly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.
31. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."
B Rationale: Blood sugar increases after meals, so this will be the best time to exercise. NPH insulin will not peak until mid-afternoon and is safe to take before a morning run. Running can be done in either the morning or afternoon. If the glucose is very elevated, the patient should postpone the run. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity
A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex
C Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).
The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results? A) Indeterminate B) Needs to be redone C) Negative D) Positive
C This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. Indeterminate isn't a term used to describe results of a PPD test. If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC.
When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A. Drug toxicity B. Polycythemia C. Infection D. Dose-limiting side effects
C. Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction .
The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A. Monitoring platelets B. Administering packed red blood cells C. Using strict aseptic technique to prevent infection D. Administering low-dose heparin therapy for clients on bedrest
C. Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.
Opportunistic diseases in HIV infection a. are usually benign. b. are generally slow to develop and progress. c. occur in the presence of immunosuppression. d. are curable with appropriate drug interventions.
Correct answer: c Rationale: Management of HIV infection is complicated by the many opportunistic diseases that can develop as the immune system deteriorates (see Table 15-10).
The client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? a) fatigue b) weakness c) weight gain d) enlarged lymph nodes
D - Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.
The most common type of leukemia in older adults is: a. acute myelocytic leukemia b. acute lymphocytic leukemia c. chronic myelocytic leukemia d. chronic lymphocytic leukemia
D - Chronic lymphocytic leukemia is a disease primarily of older adults.
Malignant disorders that arise from granulocytic cells in the bone marrow will have the primary effect of causing: a. risk for hemorrhage b. altered oxygenation c. decreased production of antibodies d. decreased phagocytosis of bacteria
D - The primary function of granulocytes is phagocytosis, a process by which white blood cells (WBCs) ingest or engulf any unwanted organism, such as bacteria, and then digest and kill it. In malignant disorders, these phagocytic cells are often reduced in number and function.
The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention? A. Avoid asbestos. B. Wear sunscreen. C. Get the human papilloma virus (HPV) vaccine. D. Do not smoke cigarettes.
D. Do not smoke cigarettes. All of these actions are part of cancer prevention; however, tobacco is the single most important source of preventable carcinogenesis. Asbestos may be found in older homes and buildings. Most schools have been through an asbestos abatement program so should not pose a risk. It would be important to share with teens who may be involved in the construction industry during the summer to be aware of asbestos risks. Although asbestos may present a risk for lung cancer, it is not a likely exposure for teens. Lifetime exposure to the sun and the use of tanning beds will increase the risk for cancer, but not as much as tobacco use. The HPV vaccine will decrease the risk for cervical cancer, but will not have as much of an impact on cancer prevention as avoiding tobacco.
When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? a) An overproduction of the antiprotease α1-antitrypsin b) Hyperinflation of alveoli and destruction of alveolar walls c) Hypertrophy and hyperplasia of goblet cells in the bronchi d) Collapse and hypoventilation of the terminal respiratory unit
b) Hyperinflation of alveoli and destruction of alveolar walls In COPD there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.
The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? a) Chew a hard candy before the first puff of medication. b) Rinse the mouth with water before each puff of medication. c) Ask for a breath mint following the second puff of medication. d) Rinse the mouth with water following the second puff of medication.
b) Rinse the mouth with water following the second puff of medication. Because beclamethosone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.
After you give D50W give _________ _____ and IM ________ if no IV
complex carbs / GlucoGon
Which statement indicates to the nurse that the client needs further medication instruction about colestipol (Colestid)? a. "The medication may cause constipation, so I will increase fluid and fiber in my diet." b. "I should take this medication 1 hour after or 4 hours before my other medications." c. "I might need to take fat-soluble vitamins to supplement my diet." d. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication."
d. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication."
A nurse teaching a client who has diabetes mellitus and is taking hydrochlorothiazide 50 mg/day. The teaching should include the importance of monitoring which levels? a. Hemoglobin and hematocrit b. Blood urea nitrogen (BUN) c. Arterial blood gases d. Serum glucose (sugar)
d. Serum glucose (sugar)
DKA Patho: Absent or inadequate __________ = blood sugar goes ______________ = 3 P's: = ____ breakdown-acidosis = ______________ respirations (trying to blow off C02 to compensate for metabolic ___________. As the client becomes more acidotic the ____ goes down.
insulin / sky high / Polyuria, Polydipsia and Polyphagia / fat / Kussmauls / acidosis / LOC
Conduction heat loss
is the loss of heat from the BODY SURFACE to COOLER SURFACES in direct contact
RADIATION HEAT LOSS
is the loss of heat from the body surface to COOLER SOLID SURFACES NOT in direct contact but in relative proximity
For those that are children or have less body fat there are short ultra thin ________ available for increased comfort.
needles
alcohol affects blood _______
sugar
You should rotate ____________ an area when deciding how to rotate your insulin shots.
within - rotate within one area and then go to the other side.
A child with sickle cell anemia is being treated for a crisis. The physician orders morphine sulfate, 2 mg I.V. The concentration of the vial is 10 mg/1 ml of solution. How many milliliters of solution should the nurse administer? Record your answer using one decimal place. Answer: milliliters
0.2 milliliters RATIONALE: The nurse should calculate the volume to be given using this equation: 2 mg/X ml = 10 mg/1 ml 10X = 2 X = 0.2 ml
A nurse assessing the heart rate and rhythm of an 8-year-old child hears a murmur that's barely audible even in a quiet room. The child's heart rate is 80 beats/minute. The nurse should document her assessment findings as: 1. "Heart rate regular, grade I murmur auscultated." 2. "Heart rate bradycardic, grade I murmur auscultated." 3. "Heart rate regular, grade II murmur auscultated" 4. "Heart rate bradycardic, grade II murmur auscultated."
1. "Heart rate regular, grade I murmur auscultated." RATIONALE: A heart rate of 80 beats/minute is considered normal for an 8-year-old child. In this age-group, bradycardia is typically associated with a heart rate of less than 70 beats/minute. A grade I murmur is barely audible in a quiet room; a grade II murmur is faint but clearly audible.
Which statement indicates that a family of a dying 4-year-old may be ready to consider organ donation? 1. "My wife and I feel that our real daughter has moved on even though her body is still functioning." 2. "Those physicians aren't doing everything they can for our daughter. I know she's still in there." 3. "When will our daughter wake up and be with us?" 4. "How can some parents allow their children to be cut up like a piece of meat and given away?"
1. "My wife and I feel that our real daughter has moved on even though her body is still functioning." RATIONALE: Statements indicating that the family has accepted the grave condition of their child is a green light for approaching them about organ donation. Statements that represent the family's nonacceptance of the child's prognosis, the lack of understanding of treatments that are being given, or the misunderstanding of organ and tissue donation are indications that the family isn't ready to be approached or to make a decision.
A mother asks the nurse why her 12-month-old baby gets otitis media more frequently than her 10-year-old son. What should the nurse tell her? 1. "The baby's eustachian tubes are shorter and lie more horizontally." 2. "The baby is too young to blow his nose when he has a cold." 3. "The baby spends more time lying down than his older brother; therefore, more dirt gets in the baby's ear." 4. "The baby puts dirty toys in his mouth."
1. "The baby's eustachian tubes are shorter and lie more horizontally." RATIONALE: Infants and young children are more prone to otitis media because their eustachian tubes are shorter and lie more horizontally. Pathogens from the nasopharynx can more readily enter the eustachian tube of the middle ear. The inability to clear nasal passages by blowing the nose, lying down on the floor, and putting dirty toys in the mouth don't increase the tendency toward otitis media.
A child with iron deficiency anemia is ordered ferrous sulfate (Ferralyn), an oral iron supplement. When teaching the child and parent how to administer this preparation, the mother asks why she needs to mix the supplement with citrus juice. Which response by the nurse is best? 1. "The vitamin C in the citrus juice helps with iron absorption." 2. "Having food and juice in the stomach helps with iron absorption." 3. "The citrus juice counteracts the unpleasant taste of the iron." 4. "There isn't a specific reason for it."
1. "The vitamin C in the citrus juice helps with iron absorption." RATIONALE: Administering an oral iron supplement such as ferrous sulfate with citrus juice or another vitamin C source enhances its absorption. Preferably, doses should be administered between meals because gastric acidity and absence of food promote iron absorption. Although citrus juice may improve the taste of an oral iron supplement, this isn't the primary reason for mixing the two together. Telling the mother that there isn't a specific reason for mixing the supplement with citrus juice is inappropriate and inaccurate.
A nurse is teaching parents about the nutritional needs of their full-term infant, age 2 months, who's breast-feeding. Which response shows that the parents understand their infant's dietary needs? 1. "We won't start any new foods now." 2. "We'll start the baby on skim milk." 3. "We'll introduce cereal into the diet now." 4. "We should add new fruits to the diet one at a time."
1. "We won't start any new foods now." RATIONALE: The parents show understanding of their infant's dietary needs by stating they won't start any new foods. Breast milk provides all the nutrients a full-term infant needs for the first 6 months. They shouldn't provide skim milk because it doesn't have sufficient fat for infant growth. The parents also shouldn't provide solid foods, such as cereal and fruit, before age 6 months because an infant's GI tract doesn't tolerate them well.
The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client? 1. A nurse who just discharged two clients with newly diagnosed diabetes 2. A nurse whose patient with asthma has decreasing oxygen saturation levels 3. A nurse caring for a client who is paralyzed and has no visiting family 4. A nurse who is about to start a complicated wet-to-damp dressing change
1. A nurse who just discharged two clients with newly diagnosed diabetes RATIONALE: Having just discharged two clients, this nurse has a low client load and she's able to accept a new assignment. The client with asthma requires constant monitoring by the nurse until his situation is resolved. Simple tasks and procedures are commonly more time-consuming when clients with paralysis are involved because these clients can't directly aid in their own care. Additional time must also be allotted for the nurse about to undertake a complicated procedure, such as a wet-to-damp dressing change.
A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? 1. A 2-year-old child who nearly drowned 2 days earlier 2. A 19-month-old infant who had surgery for a fractured tibia 12 hours ago 3. A 6-month-old infant who has gastroenteritis and vomits every 30 minutes 4. A 17-month-old infant who lost consciousness 2 hours earlier because of a head injury
1. A 2-year-old child who nearly drowned 2 days earlier RATIONALE: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. His status could quickly become very critical.
A charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse? 1. A stable 6-month-old infant with pneumonia 2. A newly admitted 1-month-old infant with bronchiolitis 3. A newly admitted 15-year-old child with diabetic ketoacidosis 4. A 12-year-old child admitted for chemotherapy
1. A stable 6-month-old infant with pneumonia RATIONALE: Of the clients listed, the most appropriate assignment for a licensed practical nurse is the stable 6-month-old infant admitted with pneumonia. Because they require close assessment, a newly admitted infant with bronchiolitis, a 15-year-old with diabetic ketoacidosis, and a 12-year-old who requires chemotherapy should be cared for by a registered nurse.
A nurse is teaching an adolescent with inflammatory bowel disease about treatment with corticosteroids. Which adverse effects are concerns for this client? Select all that apply. 1. Acne 2. Hirsutism 3. Mood swings 4. Osteoporosis 5. Growth spurts 6. Adrenal suppression
1. Acne 2. Hirsutism 3. Mood swings 4. Osteoporosis 6. Adrenal suppression RATIONALE: Adverse effects of corticosteroids include acne, hirsutism, mood swings, osteoporosis, and adrenal suppression. Steroid use in children and adolescents may cause delayed growth, not growth spurts.
A mother tells the nurse that her 4-year-old child is a very poor eater. What is the nurse's best recommendation for helping the mother increase her child's nutritional intake? 1. Allow the child to feed herself. 2. Use specially designed dishes for children — for example, a plate with the child's favorite cartoon character. 3. Only serve the child's favorite foods. 4. Allow the child to eat at a small table and chair by herself.
1. Allow the child to feed herself. RATIONALE: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation but wouldn't be an effective approach on their own. It's important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation of allowing the child to feed herself.
Which action should a nurse include in the care plan for a 2-month-old infant with heart failure? 1. Allow the infant to rest before feeding. 2. Bathe the infant and administer medications before feeding. 3. Weigh and bathe the infant before feeding. 4. Feed the infant when he cries.
1. Allow the infant to rest before feeding. RATIONALE: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends energy when crying; therefore, it's best if the infant doesn't cry.
A toddler with a ventricular septal defect is receiving digoxin (Lanoxin) to treat heart failure. Which assessment finding should be the nurse's priority concern? 1. Bradycardia 2. Tachycardia 3. Hypertension 4. Hyperactivity
1. Bradycardia RATIONALE: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.
A disabled school-age child whose parents are overprotective may display which characteristics? 1. Dependency, fearfulness, and lack of outside interests 2. Extreme independence, defiance, and a high level of risk taking 3. Shyness and loneliness 4. Pride and confidence in one's ability to cope
1. Dependency, fearfulness, and lack of outside interests RATIONALE: Disabled children whose parents are overprotective tend to have marked dependency, fearfulness, inactivity, and lack of outside interests. Children who are raised by oversolicitous and guilt-ridden parents are often overly independent, defiant, and high-risk takers. Children who are reared by parents who emphasize the child's deficits and tend to isolate the child may appear shy and lonely. Children who are reared by parents who establish reasonable limits have pride and confidence in their ability to cope successfully.
When teaching an antepartal client about the passage of the fetus through the birth canal during labor, the nurse describes the cardinal mechanisms of labor. Place these events in the proper sequence in which they occur: 1. Flexion 2. External rotation 3. Descent 4. Expulsion 5. Internal Rotation 6. Extension
1. Descent 2. Flexion 3. Internal rotation 4. Extension 5. External rotation 6. Expulsion DFI EEE
A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome? 1. Fever, decreased level of consciousness (LOC), and impaired liver function 2. Joint inflammation, red macular rash with a clear center, and low-grade fever 3. Peripheral edema, fever for 5 or more days, and "strawberry tongue" 4. Red, raised "bull's eye" rash, malaise, and joint pain
1. Fever, decreased level of consciousness (LOC), and impaired liver function RATIONALE: Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It's commonly associated with the administration of aspirin. The child presents with fever and decreased LOC, which can lead to coma and death. As the disease progresses, the child also develops impaired liver function. A child with joint pain, a red macular rash with a clear center, and a low-grade fever probably has rheumatic fever. A child presenting with peripheral edema, fever for more than 5 days, and a "strawberry tongue" probably has Kawasaki disease. A child with a red, raised "bull's eye" rash, malaise, and joint pain should be tested for Lyme disease.
Which of the following nursing actions is required before a client in labor receives an epidural? 1. Give a fluid bolus of 500 ml 2. check for maternal pupil dilation 3. assess maternal reflexes 4. assess maternal gait
1. Give a fluid bolus of 500 ml one of the major adverse effects of epidural admin is hypotension therefore, a 500ml fluid bolus is usually admin to help prevent hypotension in the client who wishes to receive an epidural for pain relief. assessments of meternal reflexes, pupil response and gait arent necessary
When examining school-age and adolescent children, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening? 1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. 2. Listen for a clicking sound as the child abducts the hips. 3. Have the child run the heel of one foot down the shin of the other leg while standing. 4. Have the child shrug the shoulders as the nurse applies mild pressure to the shoulders.
1. Have the child stand firmly on both feet and bend forward at the hips, with the trunk exposed. RATIONALE: To screen for scoliosis, a lateral curvature of the spine, the nurse has the child stand firmly on both feet with the trunk exposed and examines the child from behind, checking for asymmetry of the shoulders, scapulae, or hips. The nurse then asks the child to bend forward at the hips and inspects for a rib hump, a sign of scoliosis. Listening for a clicking sound while the child abducts the hips is appropriate when screening for congenital hip dysplasia. The heel-to-shin test evaluates cerebellar function and having the child shrug the shoulders against mild resistance helps evaluate the integrity of cranial nerve XI.
An infant undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively? 1. Ineffective airway clearance 2. Imbalanced nutrition: Less than body requirements 3. Interrupted breast-feeding 4. Hypothermia
1. Ineffective airway clearance RATIONALE: Ineffective airway clearance has the highest priority in the immediate postoperative period. The infant's airway must be carefully assessed and frequent suctioning may be necessary to remove mucus while taking care not to pass the catheter as far as the suture line. Assess breath sounds, respiratory rate, skin color, and ease of breathing. Because of the risk of edema and airway obstruction, keep a laryngoscope and endotracheal intubation equipment readily available. Imbalanced nutrition, Interrupted breast-feeding, and Hypothermia are also important during the postoperative period but only after a patent airway is ensured.
A preschool child is admitted to the pediatric unit with acute nephritis. Which electrolyte replacement agent is used as an adjunct to treatment for this condition? 1. Magnesium sulfate 2. Calcium glubionate 3. Potassium chloride 4. Sodium lactate
1. Magnesium sulfate RATIONALE: Magnesium sulfate is an electrolyte that's used as an adjunct to treat acute nephritis. It also is used to treat seizures and severe toxemia. Calcium glubionate, potassium chloride, and sodium lactate aren't therapeutic in acute nephritis and, in fact, may worsen the condition.
A toddler is admitted to the facility with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip (Labstix). Which finding is the nurse most likely to see? 1. Proteinuria 2. Glycosuria 3. Ketonuria 4. Polyuria
1. Proteinuria RATIONALE: In nephrotic syndrome, the glomerular membrane of the kidneys becomes permeable to proteins, resulting in massive proteinuria. Nephrotic syndrome typically doesn't cause glycosuria or ketonuria. Because the syndrome causes fluids to shift from plasma to interstitial spaces, it's more likely to decrease urine output than to cause polyuria (excessive urine output).
A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child? 1. Providing fluids 2. Maintaining protective isolation 3. Applying cool compresses to affected joints 4. Administering antipyretics as ordered
1. Providing fluids RATIONALE: During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the highest priority is providing I.V. and oral fluids, which promotes hemodilution and aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis.
A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breath, and a decreased oxygen saturation level. What should the nurse do first? 1. Suction the tracheostomy. 2. Turn the child to a side-lying position. 3. Administer pain medication. 4. Perform chest physiotherapy.
1. Suction the tracheostomy. RATIONALE: Diaphoresis, increased heart rate, increased respiratory effort, and decreased oxygen saturation are signs that mucus is partially occluding the airway. Therefore, the nurse should suction the tracheostomy first to prevent full occlusion. Turning the child to a side-lying position won't remove mucus from the airway. The child may require pain medication after his airway has been cleared if his condition warrants it. Chest physiotherapy will help drain excess mucus from the lungs but not from a tracheostomy.
When a nurse answers the telephone at the front desk, a caller identifies himself as a child's father and asks how the child is doing. The nurse knows that the child's father hasn't had contact with his son for 2 years. What should the nurse do? 1. Tell the caller that she can't give out information about a client's condition. 2. Report the call to social services. 3. Give the caller a basic update on the child's prognosis. 4. Transfer the call to the child's room.
1. Tell the caller that she can't give out information about a client's condition. RATIONALE: A nurse must uphold her institution's policies and Health Insurance Portability and Accountability Act regulations by not providing information in response to questions about a client's care. Contacting social services would be indicated if the father came to the facility and demanded information. The nurse shouldn't transfer the call to the child's room. She doesn't know anything about the father's relationship with the child, and the contact might distress the child.
The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle. 2. The client must be repeatedly exposed to HIV before becoming infected. 3. The client may be in the primary infection phase of an HIV infection. 4. The antibody test is negative because the client has a different flu virus.
1. The client may be in the primary infection stage when the body has not had time to develop antibodies to the HIV virus. 2. Repeated exposure to HIV increases the risk of infection, but it only takes one exposure to develop an infection. *3. The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV.* 4. The client may or may not have a different virus, but this is not the reason the test is negative. TEST-TAKING HINT: Answer options "1" and "4" assume the client is negative for the HIV virus. Therefore, these options should be eliminated as correct answers unless the test taker is completely sure the statement is correct.
A child who was hospitalized for sickle cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises? 1. The parent verbalizes the need to stay away from persons with known infections. 2. The parent verbalizes appropriate dietary restrictions. 3. The parent verbalizes the need to restrict fluid intake. 4. The parent participates in an aerobic exercise program.
1. The parent verbalizes the need to stay away from persons with known infections. RATIONALE: Preventing infections through proper hand washing and staying away from persons with known infections is an important measure in preventing sickle cell crises. Dietary restrictions aren't significant in preventing these crises. The client should maintain adequate hydration, not restrict fluid intake, and should avoid strenuous activity such as aerobics.
A 13-year-old adolescent may have appendicitis. Which finding is a reliable indicator of appendicitis? 1. The severity, location, and movement of pain 2. Fever 3. A history of vomiting and diarrhea, if present 4. A history of irritability and lethargy
1. The severity, location, and movement of pain RATIONALE: The pattern of pain is a reliable indicator of acute appendicitis. It begins with a severe colicky abdominal pain that gets progressively worse. The pain starts in the midabdominal (periumbilical) region and moves to the right lower quadrant after 6 to 12 hours. The degree of fever, a history of vomiting and diarrhea, and a history of irritability and lethargy are also clinical manifestations of acute appendicitis; however, these conditions can also be present in a number of other childhood illnesses so they aren't as reliable as the pattern of pain.
A physician ordered an X-ray for an adolescent in the pediatric unit. With whom should the nurse collaborate to carry out this order? 1. Transport personnel 2. Physician 3. Pharmacist 4. Circulating nurse
1. Transport personnel RATIONALE: Transport personnel are responsible for escorting clients throughout the hospital, including to various test locations. The physician isn't required to transport any client to the radiology department. The pharmacist is responsible for anything related to medications. The circulating nurse assists with surgical procedures in the operating room; she doesn't help transport clients to the X-ray department
Which situation violates a hospitalized adolescent's right to confidentiality? 1. Two nurses talk about the adolescent on an elevator on their way to lunch. 2. The adolescent talks about his disease to someone in the hallway. 3. A physician discusses treatment plans with the adolescent in his mother's presence. 4. A physician discusses a new medication for the adolescent while on the phone with the pharmacist.
1. Two nurses talk about the adolescent on an elevator on their way to lunch. RATIONALE: The elevator isn't a secure area in which to talk about any client, including an adolescent; anyone could overhear the nurses' conversation. A client isn't breaching his own confidentiality if he volunteers information about himself. When a client is present for the conversation, he can object at any time to the content of the conversation. Physicians and other health care providers are expected to discuss clients and cases, as long as they do so within the context of a professional relationship and the discussion is necessary for the course of treatment.
A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order: 1. a barium enema. 2. suprapubic aspiration. 3. nasogastric (NG) tube insertion. 4. indwelling urinary catheter insertion.
1. a barium enema. RATIONALE: A nurse should expect the physician to order a barium enema because this test is commonly used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.
A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and: 1. a barking cough. 2. a high fever. 3. sudden onset. 4. dysphagia.
1. a barking cough. RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low grade. Croup has a gradual onset, and dysphagia isn't a symptom.
A nurse discussing injury prevention with a group of workers at a day-care center is focusing on toddlers. When discussing this age-group, the nurse should stress that: 1. accidents are the leading cause of death among toddlers. 2. the risk for homicide is highest among toddlers. 3. toddlers can distinguish right from wrong. 4. toddlers will always chase a ball that rolls into the street.
1. accidents are the leading cause of death among toddlers. RATIONALE: The leading cause of death in toddlers is accidents, so it's important for parents, family members, and childcare providers to understand the importance of accident prevention. Toddlers don't have the highest risk for homicide. Toddlers are just beginning to understand right from wrong, but don't understand the consequences of their actions. Although many children will chase balls or toys into the street, not all children will do so.
A school-age child presents to the office for a routine examination. Given the child's developmental level, a nurse should give highest priority to: 1. allowing the child to change into a gown while she isn't in the room. 2. allowing the child to play with medical equipment before the examination begins. 3. asking the parents to leave the room during the child's examination. 4. encouraging the child to hold a stuffed animal during the examination.
1. allowing the child to change into a gown while she isn't in the room. RATIONALE: School-age children tend to be very modest. The nurse should allow them to change into gowns while she isn't in the examination room. Children shouldn't have to take off their underwear for routine medical examinations. Playing with medical equipment is characteristic of younger children. The nurse shouldn't ask parents to leave the room unless the child requests that they not be present. A school-age child may feel too old to hold a stuffed animal during the examination.
An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to: 1. ask to see a copy of the advance directive. 2. administer oxygen to the infant while awaiting the physician's orders. 3. provide palliative care for the infant and his family. 4. contact the nursing supervisor for assistance.
1. ask to see a copy of the advance directive. RATIONALE: In order to have information about how to proceed, the nurse must evaluate the advance directive. Until the nurse evaluates the legitimacy and content of the advance directive, it's inappropriate for her to administer oxygen or provide palliative care. The nurse should ask to see the advanced directive before proceeding with care; contacting the nursing supervisor isn't the most appropriate initial response.
A nurse caring for an adolescent in traction should: 1. assess pin sites every shift and as needed. 2. ensure that the rope knots catch on the pulley. 3. add and remove weights at the adolescent's request. 4. put all his joints through range of motion every shift.
1. assess pin sites every shift and as needed. RATIONALE: Nursing care for a client in traction includes assessing pin sites every shift and as needed and ensuring that the knots in the rope don't catch on the pulley. The nurse should add and remove weights at the physician's order, not at the adolescent's request. All joints, except those immediately proximal and distal to the fracture, should be put through range of motion every shift.
When performing an assessment on a neonate, which assessment finding is MOST SUGGESTIVE of hypothermia? 1. bradycardia 2. hyperglycemia 3. metabolic alkalosis 4. shivering
1. bradycardia hypothermic neonates become bradycardic proportional to the degree of core temp HYPOGLYCEMIA is seen in HYPOTHERMIC NEONATES Shivering is rarely observed in neonates metabolic ACIDOSIS, not alkalosis is seen due to slowed resp
A nurse discovers a 5-year-old child who's unresponsive, apneic, and pulseless. The correct sequence of events that should follow is: 1. call for help, open the airway, provide two rescue breaths, and begin compressions at a rate of 100 per minute. 2. open the airway, provide two rescue breaths, and begin compressions at a rate of 100 per minute. 3. call for help, open the airway, provide two rescue breaths, and begin compressions at a rate of 80 per minute. 4. call for help, continue to attempt to arouse, and assess for breathlessness and lack of pulse until a second rescuer arrives.
1. call for help, open the airway, provide two rescue breaths, and begin compressions at a rate of 100 per minute. RATIONALE: The nurse should call for help, open the airway, provide two rescue breaths, begin compressions at a rate of 100 per minute, give two breaths for every 30 compressions, continue for approximately 2 minutes, and reassess. This is the accepted sequence defined by the American Heart Association for one-rescuer child cardiopulmonary resuscitation (CPR). Calling for help should be the first action to ensure that assistance arrives quickly. The accepted sequence of events for one-rescuer adult CPR is to call for help, open the airway, provide two rescue breaths, begin compressions at a rate of 100 per minute, give two breaths for every 30 compressions, continue for approximately 2 minutes, and reassess. As soon as unresponsiveness, breathlessness, or lack of pulse has been established, CPR should begin immediately.
A mist tent contains a nebulizer that creates a cool, moist environment for an infant with an upper respiratory tract infection. The cool humidity helps the infant breathe by: 1. decreasing respiratory tract edema. 2. avoiding anxiety. 3. drying secretions. 4. increasing fluid intake.
1. decreasing respiratory tract edema. RATIONALE: The cool humidity of the mist tent helps the infant breathe by decreasing respiratory tract edema. The confinement of the mist tent can increase anxiety, not avoid it. Also, the tent liquefies secretions, rather than drying them, and it doesn't increase the infant's fluid intake.
A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is: 1. developmental readiness of the child. 2. consistency in approach. 3. the mother's positive attitude. 4. developmental level of the child's peers.
1. developmental readiness of the child. RATIONALE: The most important factor is developmental readiness because if the child isn't developmentally ready, both the child and parent will become frustrated. Consistency is important when toilet training is started; the mother's positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn't useful.
A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: 1. help the family prepare for the infant's imminent death. 2. implement measures to facilitate the attachment process. 3. provide emotional support so the family can adjust to the birth of an infant with health problems. 4. prepare the family for the extensive surgical procedures the infant will require.
1. help the family prepare for the infant's imminent death. RATIONALE: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive.
A charge nurse is at the front desk when a woman demands information about a child who has been admitted on the unit. The nurse should: 1. inform the woman that the Health Insurance Portability and Accountability Act (HIPAA) prevents her from disclosing the information. 2. direct the woman to the child's room. 3. call security because of the woman's angry demeanor. 4. refer to the child's chart and give the woman basic information.
1. inform the woman that the Health Insurance Portability and Accountability Act (HIPAA) prevents her from disclosing the information. RATIONALE: The nurse has a legal responsibility to follow HIPAA guidelines regarding client information. She must never disclose information, such as a room number, about a client or his condition without the consent of the client or family members. The nurse doesn't need to call security at this point.
When making ethical decisions about caring for preschoolers, a nurse should remember to: 1. provide beneficial care and avoid harming the child. 2. make decisions that will prevent legal trouble. 3. do what she would do for her own child or loved ones. 4. be sure to do what the physician says.
1. provide beneficial care and avoid harming the child. RATIONALE: Nurses must provide beneficial care and avoid harming all clients. A nurse shouldn't base any decision solely on the desire to prevent legal trouble, on her own feelings for her loved ones, or what the physician says.
A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: 1. production of thick, sticky mucus 2. harsh, nonproductive cough 3. stridor 4. unilateral decrease in breath sounds
1. production of thick, sticky mucus RATIONALE: Cystic fibrosis is associated with the production of thick, sticky mucus. Cystic fibrosis isn't associated with harsh, nonproductive coughing or with stridor or unilateral decrease in breath sounds.
A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is: 1. skin traction applied to a lower extremity, with the extremity suspended above the bed. 2. skeletal traction applied to a lower extremity. 3. skin traction applied to an extended lower extremity. 4. skin traction applied bilaterally to the lower extremities.
1. skin traction applied to a lower extremity, with the extremity suspended above the bed. RATIONALE: Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.
A child is being discharged with proventil (Albuterol) nebulizer treatments. The nurse should instruct the parents to watch for: 1. tachycardia. 2. bradypnea. 3. urine retention. 4. constipation.
1. tachycardia. RATIONALE: Proventil is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases. Signs and symptoms of proventil toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, and dizziness. Unusually slow respirations, urine retention, and constipation aren't associated with proventil toxicity.
A 22-month-old 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. RATIONALE: 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.
Two days after circumcision, the nurse notes a yellow - white exudate around the head of the neonates penis. What would be the most appropriate nursing intervention? 1. Leave the area alone as this is a normal finding 2. report findings to physician and document it 3. Take the neonate's temperature bc an infection is suspected 4. Try to remove the exudate with a warm washcloth
1. the yellow white exudate is part of the granulation process and a normal finding for a healing penis after circumcision therefore, notifying the doctor isnt necessary theres no indication of an infection that would necessitate taking the neonates temp the exudate shouldnt be removed
A client with a fever is ordered to receive sulfonamides for an infection. the nurse needs to evaluate the client for which of the following during the course of therapy. select all
1.) respond to drug therapy 2.) occurrence of the adverse reactions 3.) decrease in temperature
A parent calls the pediatric clinic to express concern over her child's eating habits. She says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of: 1. toddlers. 2. preschool-age children. 3. school-age children. 4. adolescents.
1. toddlers. RATIONALE: The nurse knows that erratic eating is typical of toddlers because the physiologic need for food decreases at about age 18 months as growth declines from the rapid rate of infancy. The toddler also develops strong food and taste preferences, sometimes eating just one type of food for days or weeks and then switching to another.
If an infant's I.V. access site is in an extremity, the nurse should: 1. use a padded board to secure the extremity. 2. restrain all four extremities. 3. restrain the extremity to the bed's side rail. 4. allow the extremity to be loose.
1. use a padded board to secure the extremity. RATIONALE: The nurse should use a padded board because it's adequate to secure the extremity. Restraining all four extremities can be harmful and uncomfortable for the child. Restraining the extremity to the bed's side rail limits the child's movement; the child may bang against the rail and cause injury. Allowing the extremity to be loose increases the risk that the I.V. will infiltrate or be dislodged by the infant
When telling a 4-year-old child about an upcoming procedure, the nurse's most important consideration is to: 1. use simple terms. 2. speak loudly and clearly. 3. offer a toy to keep the child happy. 4. include every detail.
1. use simple terms. RATIONALE: When explaining a procedure to a 4-year-old child, the nurse must use simple terms that the child can understand. Speaking loudly may provoke anxiety. Distracting the child with a toy is more appropriate during the procedure rather than before it. Because preschoolers have a limited attention span, the nurse should provide only the necessary basic facts — not every detail — to prevent anxiety.
The most appropriate site for a nurse to use to administer an I.M. injection to a 2-year-old child is the: 1. ventrogluteal muscle. 2. pectoral muscle. 3. femoral muscle. 4. deltoid muscle.
1. ventrogluteal muscle. RATIONALE: When administering an I.M. injection to a 2-year-old child, the nurse might select the ventrogluteal muscle if the muscle is well developed. However, the preferred site is the vastus lateralis. The pectoral, femoral, and deltoid muscles aren't appropriate injection sites for a child.
A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction? 1. "Give the iron preparation with milk." 2. "Give the elixir with water or juice." 3. "Monitor the child for episodes of diarrhea." 4. "Give the iron preparation before meals."
2. "Give the elixir with water or juice." RATIONALE: Because iron preparations may stain the teeth, the nurse should instruct the parents to give the elixir with water or juice. The iron preparation shouldn't be given with milk because milk impedes iron absorption. This preparation may darken the stools and cause constipation, not diarrhea; parental instruction regarding increased fluid intake and fiber intake can relieve constipation. To prevent GI upset, the nurse should instruct the parents to mix the iron preparation with water or fruit juice and have the child take it with, not before, meals. (Giving it with fruit juice may be preferable because vitamin C enhances iron solubility and absorption.)
A nurse is teaching the mother of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? 1. "I hope my baby will come home from the hospital." 2. "I know that this disease is serious and can lead to asthma." 3. "My baby needs to be cured this time so it won't happen again." 4. "My baby has been sick. A machine will help him breathe."
2. "I know that this disease is serious and can lead to asthma." RATIONALE: By saying bronchiolitis places the child at risk for developing asthma, the mother demonstrates understanding of her infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.
An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care? 1. "I use a soft toothbrush to clean my teeth." 2. "I remove white patches from my tongue and cheeks with my toothbrush." 3. "I rinse my mouth every 2 to 4 hours with a solution of baking soda and water." 4. "I don't use commercial mouthwashes."
2. "I remove white patches from my tongue and cheeks with my toothbrush." RATIONALE: White patches on the tongue and oral mucosa indicate infection; the adolescent should report the patches, not remove them. Using a soft toothbrush is appropriate because it prevents injury to the fragile oral mucosa. Rinsing his mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution helps prevent stomatitis. Avoiding commercial mouthwashes is appropriate because they may contain alcohol, which may dry the oral mucosa.
A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her infant can't sit alone or roll over. An appropriate response by the nurse would be: 1. "This is very abnormal. Your child must be sick." 2. "Let's see about further developmental testing." 3. "Don't worry, this is normal for her age." 4. "Maybe you just haven't seen her do it."
2. "Let's see about further developmental testing." RATIONALE: Stating that further developmental testing is necessary is appropriate because at age 12 months a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Saying the infant's behavior is abnormal or suggesting that the mother hasn't seen her infant do these milestones isn't therapeutic and can cut off communication with the mother. Telling the mother that the infant's behavior is normal misleads the mother with false reassurance.
A child, age 3, is admitted to the pediatric unit with dehydration after 2 days of nausea and vomiting. The mother tells the nurse that her child's illness "is all my fault." How should the nurse respond? 1. "Maybe next time you'll bring the child in sooner." 2. "Tell me why you think this is your fault." 3. "Try not to cry in front of the child. It'll only upset her." 4. "Don't be so upset. Your child will be fine."
2. "Tell me why you think this is your fault." RATIONALE: Having the mother explain why she feels the illness is her fault is appropriate because many parents feel responsible for their child's illness and may need instruction about the actual cause of the illness. Pointing out that the mother could have brought the child in sooner could increase the mother's feelings of guilt. Telling the mother not to cry or be upset ignores her feelings.
After being hospitalized for status asthmaticus, a child, age 5, is discharged with prednisone (Deltasone) and other oral medications. Two weeks later, when the child comes to the clinic for a checkup, the nurse instructs the mother to gradually decrease the dosage of prednisone, which will be discontinued. The mother asks why prednisone must be discontinued. How should the nurse respond? 1. "Steroids increase the appetite, leading to obesity with prolonged use." 2. "Long-term steroid therapy may interfere with a child's growth." 3. "The child may develop a hypersensitivity to steroids with continued use." 4. "Prolonged steroid use may cause depression."
2. "Long-term steroid therapy may interfere with a child's growth." RATIONALE: Steroids suppress release of adrenocorticotropic hormone from the pituitary gland, stopping production of endogenous hormones by the adrenal cortex. Because prolonged adrenal suppression may cause growth retardation in a child, the duration and dosage of steroid therapy must be kept to a minimum. Steroids also may cause central nervous system effects, such as euphoria, insomnia, and mood swings. Although steroids increase the appetite, this effect isn't the reason for limiting their use in children. Steroids are present in the body, so hypersensitivity isn't a problem, and they're likely to cause euphoria, not depression.
A boy, age 4, begins to use curse words. Concerned about this behavior, his parents ask the nurse how to discourage it. Which advice should the nurse offer? 1. "Just ignore it. He'll grow out of it." 2. "Tell him it isn't acceptable and he'll be disciplined if he continues to do it." 3. "Tell him that good little boys don't use curse words." 4. "Tell him that his behavior makes you angry."
2. "Tell him it isn't acceptable and he'll be disciplined if he continues to do it."
A 15-year-old girl with a urinary tract infection is admitted to the facility. She tells the nurse she hopes she's pregnant. How should the nurse respond? 1. "Does your mother know about this?" 2. "Tell me what being pregnant would mean to you." 3. "Congratulations. Does the baby's father know?" 4. "I hope you aren't pregnant; you're too young."
2. "Tell me what being pregnant would mean to you." RATIONALE: When talking with adolescents, it's best to get their viewpoints and thoughts before offering suggestions or giving advice. Doing so promotes therapeutic communication. Asking whether the girl's mother knows about her condition and desire to be pregnant or asking about the baby's father focuses attention away from the adolescent. A statement about the girl being too young to be pregnant is a value judgment and inappropriate for the nurse to make.
While performing an assessment, a nurse observes a 6-month-old infant transferring an object from one hand to another. The mother tells the nurse this is a new behavior and asks if it is normal. What is the best response by the nurse? 1. "Your baby has very advanced motor skills." 2. "This behavior is normal for a 6-month-old infant." 3. "Can your baby move the object into a container?" 4. "Don't worry. Your baby will catch up soon."
2. "This behavior is normal for a 6-month-old infant." RATIONALE: The nurse should say this behavior is normally seen because an infant typically transfers objects from one hand to another between ages 6 and 7 months, so the infant is demonstrating normal developmental behavior. Placing objects in a container occurs by age 12 months so the nurse doesn't need to ask about this milestone. Telling the mother not to worry and that the baby will catch up is not only ineffective communication, it's also unnecessary because the infant is exhibiting normal behavior.
A nurse should begin screening for lead poisoning when a child reaches which age? 1. 6 months 2. 12 months 3. 18 months 4. 24 months
2. 12 months RATIONALE: The nurse should start screening a child for lead poisoning at age 12 months and perform repeat screenings at 24 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron deficiency anemia at age 6 months. Regular dental visits should begin at age 24 months.
At what age should a boy be taught how to do a monthly testicular self-examination? 1. 8 years 2. 12 years 3. 16 years 4. When he becomes sexually active
2. 12 years RATIONALE: Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures.
The parents of a child with cystic fibrosis, an autosomal recessive disorder, are considering having a second child. Each parent is heterozygous for the cystic fibrosis trait. What is the chance that their second child will manifest the disorder? 1. 0% 2. 25% 3. 50% 4. 100%
2. 25% RATIONALE: To manifest, or express, an autosomal recessive disorder, a child must inherit the trait from both parents. A heterozygous person carries one normal gene and one affected gene and doesn't express the disorder. Therefore, a child of two heterozygous parents has a one-in-four (25%) chance of manifesting an autosomal recessive disorder. Also, outcomes of previous pregnancies don't influence the probability of subsequent offspring expressing the genetic disorder.
Intraosseous infusion of a medication would be most appropriate for which child? 1. An 18-month-old child with cystic fibrosis 2. A 2-year-old child with a ruptured spleen and hypovolemia 3. A 4-year-old child with celiac disease 4. A 5-year-old child with status asthmaticus
2. A 2-year-old child with a ruptured spleen and hypovolemia RATIONALE: In an emergency, intraosseous drug administration is typically used when a child is critically ill and younger than age 3. The 2-year-old child with a ruptured spleen and hypovolemia meets these criteria.
When assessing a child, age 3 months, who has been diagnosed with heart failure, the nurse expects which finding? 1. Bounding peripheral pulses 2. A gallop heart rhythm 3. Widened pulse pressure 4. Bradycardia
2. A gallop heart rhythm RATIONALE: Heart failure may cause a gallop heart rhythm in a child. Bounding peripheral pulses, widened pulse pressure, and bradycardia aren't associated with heart failure.
A nurse is preparing to teach a 13-year-old adolescent with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? 1. Adolescents are unable to follow detailed instructions. 2. Adolescents are worried about appearing different from their peers. 3. Adolescents' fine motor coordination isn't sufficiently developed to administer treatments. 4. Adolescents have a well-developed sense of self-identity.
2. Adolescents are worried about appearing different from their peers. RATIONALE: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. Adolescents are capable of following detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity; identity isn't already well-developed.
The mother of an 11-month-old infant reports to the nurse that her infant sleeps much less than other children. The mother asks the nurse whether her infant is getting sufficient sleep. What should be the nurse's initial response? 1. Reassure the mother that each infant's sleep needs are individual. 2. Ask the mother for more information about the infant's sleep patterns. 3. Instruct the mother to decrease the infant's daytime sleep to increase his nighttime sleep. 4. Inform the mother that her infant's growth and development are appropriate for his age, so sleep isn't a concern.
2. Ask the mother for more information about the infant's sleep patterns. RATIONALE: The nurse needs more information about the infant's sleep patterns to rule out potential problems before determining whether the infant is getting enough sleep. The nurse shouldn't offer advice or reassurance without knowing more about the infant's specific sleep habits.
A 7-year-old child is admitted to the hospital for a course of I.V. antibiotics. What should the nurse do before inserting the peripheral I.V. catheter? Select all that apply. 1. Explain the procedure to the child immediately before the procedure. 2. Apply a topical anesthetic to the I.V. site before the procedure. 3. Ask the child which hand he uses for drawing. 4. Explain the procedure to the child using abstract terms. 5. Don't let the child see the equipment to be used in the procedure. 6. Tell the child that the procedure won't hurt.
2. Apply a topical anesthetic to the I.V. site before the procedure. 3. Ask the child which hand he uses for drawing. RATIONALE: Topical anesthetics reduce the pain of a venipuncture. The topical anesthetic cream should be applied about 1 hour before the procedure and requires a physician's order. Asking which hand the child draws with helps to identify the dominant hand. The I.V. should be inserted into the opposite extremity so that the child can continue to play and do homework with minimal disruption. Younger school-age children don't have the capability for abstract thinking. The procedure should be explained using simple words, and definitions of unfamiliar terms should be provided. The child should have the procedure explained to him well before it takes place so that he has time to ask questions. Although the topical anesthetic will relieve some pain, there's usually some pain or discomfort involved in venipuncture, so the child shouldn't be told otherwise.
Before a routine checkup, an 8-month-old infant sits contentedly on the mother's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first? 1. Measure the head circumference. 2. Auscultate the heart and lungs. 3. Elicit the pupillary reaction. 4. Weigh the child.
2. Auscultate the heart and lungs. RATIONALE: The nurse should first ausculate the heart and lungs because this assessment rarely distresses an infant. Placing a tape measure on the infant's head, shining a light in the eyes, or undressing the infant before weighing him may cause distress, making the rest of the examination more difficult.
Which action should the nurse take first when admitting an 11-year-old child in sickle cell crisis? 1. Administer oral pain medication while obtaining the child's history. 2. Begin I.V. fluids after obtaining the child's history. 3. Instruct the parents about what to expect during this hospitalization. 4. Start oxygen therapy as soon as the child's vital signs are taken.
2. Begin I.V. fluids after obtaining the child's history. RATIONALE: The nurse should obtain the child's history and then begin I.V.fluids. Fluids are one of the most important components of therapy for sickle cell crisis; they help increase blood volume and prevent sickling and thrombosis. A child experiencing a sickle cell crisis commonly has severe pain requiring the use of I.V. analgesics such as morphine, which would be administered after fluid therapy has been started. Instructing the parents about what to expect during hospitalization is important, but it isn't the first action the nurse should take. Oxygen therapy is used only if the child is hypoxic.
Which condition places the client at the greatest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20% of the body 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery
2. Burns over more than 20% of the body, Burns more than 20% of the client's total body surface are generally considered major burn injuries. When the skin is damaged by a burn the underlying tissue is left unprotected and the individual is at risk for infection. The greater the extent and deeper the depth of the burn, the higher the risk is for infection. Prosthetic devices are surgically implanted under sterile conditions to minimize risk of infection. Indwelling urinary catheters are implanted under sterile conditions and are considered closed systems where sterile technique is maintained. Laparoscopic surgery is also performed using sterile technique.
Which method is reliable for identifying a preschooler before administering a medication? 1. Check the name on the bed. 2. Check the hospital identification bracelet. 3. Ask the child his name. 4. Ask the parents at the bedside.
2. Check the hospital identification bracelet. RATIONALE: The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers or preschoolers may admit to any name, and school-age children may deny their identities in an attempt to avoid the medication. Parents aren't always at the bedside, so they shouldn't be relied on for identification.
When teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include? 1. Burning or pain with urination 2. Complaints of a stiff neck 3. Fever disappearing for longer than 24 hours, then returning 4. History of febrile seizures
2. Complaints of a stiff neck RATIONALE: The nurse should discuss complaints of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, fever that disappears for 24 hours then returns, and a history of febrile seizures should be addressed by the physician but can wait until office hours.
A child has just received a dose of theophylline I.V. for asthma. What assessment finding should the nurse expect? 1. Increased coughing because of postnasal drip 2. Decreased pulmonary wheezing 3. Stridor 4. White blood cell count of 12,000/μl
2. Decreased pulmonary wheezing RATIONALE: Methylxanthines such as theophylline are highly potent bronchodilators used to relieve asthma symptoms. The bronchodilation will result in decreased wheezing. None of the other options are seen after administration of theophylline.
When caring for a child, age 12, who's diagnosed with osteomyelitis of the left femur, the nurse should take which action first? 1. Administer I.V. antibiotics as ordered. 2. Draw blood for cultures as ordered. 3. Monitor hepatic and renal studies. 4. Prepare the child for immediate surgery.
2. Draw blood for cultures as ordered. RATIONALE: Osteomyelitis, an infectious bone disease, typically results from Staphylococcus aureus or Haemophilus influenzae. Blood cultures must be obtained to identify the causative organism and determine its sensitivity to antimicrobial agents. Although treatment may include high doses of antibiotics, blood cultures must be obtained before antibiotic therapy begins. Hepatic and renal studies are obtained during the course of antibiotic therapy to monitor the child for adverse effects. Later, surgery may be necessary to drain abscesses.
A nurse is assessing a 3-year-old child who has ingested toilet bowl cleaner. What finding should the nurse expect? 1. Reddish colored skin 2. Edematous lips 3. Hypertension 4. Lower abdominal pain
2. Edematous lips RATIONALE: A child who has ingested a caustic poison such as lye (found in toilet bowl cleaners) may develop edema, ulcers of the lips and mouth, pain in the mouth and throat, excessive salivation, dysphagia, and burns of the mouth, lips, esophagus, and stomach. Bleeding from burns in the GI tract can lead to pallor, hypotension (not hypertension), tachypnea, and tachycardia. The nurse would not expect to find reddish colored skin and lower abdominal pain because they don't commonly occur in caustic poisoning.
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? 1. Avoiding suctioning unless cyanosis occurs 2. Elevating the neonate's head and giving nothing by mouth 3. Elevating the neonate's head for 1 hour after feedings 4. Giving the neonate only glucose water for the first 24 hours
2. Elevating the neonate's head and giving nothing by mouth RATIONALE: Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate's head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status.
A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. 1. Bulging anterior fontanel 2. Fever 3. Nuchal rigidity 4. Petechiae 5. Irritability 6. Photophobia
2. Fever 3. Nuchal rigidity 5. Irritability 6. Photophobia RATIONALE: Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis.
An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect her rights during the physical examination? 1. Leave the door open. 2. Have a female health care worker present. 3. Keep the suspected attacker away from the examination room. 4. Keep the girl's friends (who are waiting in the lounge area) informed of her medical condition.
2. Have a female health care worker present. RATIONALE: A female health care provider should be present to observe an examination performed by a male health care provider. Leaving the door open and informing the girl's friends about her condition violates her right to privacy and confidentiality. Although the suspected attacker should be kept away from the examination room, having a female health care worker present during the examination best protects the girl's rights.
A 3-year-old child is admitted to the hospital with an acute exacerbation of asthma. The child's history reveals that the child was exposed to chickenpox 1 week ago. When would this child require isolation? 1. Isolation isn't required. 2. Immediate isolation is required. 3. Isolation is required 10 days after exposure. 4. Isolation is required 12 days after exposure.
2. Immediate isolation is required. RATIONALE: Immediate isolation is required because the incubation period for chickenpox is 2 to 3 weeks, and a client is commonly isolated 1 week after exposure to avoid the risk of an outbreak. A person is infectious from 1 day before eruption of lesions to 6 days after the lesions have formed crusts. Isolation 10 or 12 days after exposure would be too late, putting others at risk for exposure.
A nurse is caring for a 4-year-old child with end-stage leukemia. The child's physician has ordered a lumbar puncture. His mother, who has legal custody, has refused to give consent for the child to undergo the procedure. However, the child's father is demanding that the procedure be performed. What should the nurse do first? 1. Prepare the child for the lumbar puncture because the father wants the procedure to be performed. 2. Inform the father that the procedure won't be performed because the mother didn't consent. 3. Ask the child if he would like to have the procedure. 4. Contact social services and the child's physician.
2. Inform the father that the procedure won't be performed because the mother didn't consent. RATIONALE: The parent who has legal custody of a child has medical decision-making rights for that child. The other parent could contest the decision but would need to seek legal counsel. After informing the father that the procedure won't be performed at this time, the nurse should make the physician and social services aware of the situation in case additional problems arise.
For an 8-month-old infant, which toy promotes cognitive development? 1. Finger paint 2. Jack-in-the-box 3. A small rubber ball 4. A play gym strung across the crib
2. Jack-in-the-box RATIONALE: According to Piaget's theory of cognitive development, an 8-month-old child will look for an object once it disappears from sight to develop the cognitive skill of object permanence. Therefore, a jack-in-the-box would promote cognitive development. Finger paint and small balls are potentially dangerous because infants frequently put their fingers or objects in their mouths. Anything strung across a crib, such as a play gym, is a safety hazard — especially to a child who may use it to pull up to a standing position.
It takes about __-__ weeks for an arm to heal
3 - 6
Prefilled syringes can be stored for up to __ weeks in the refrigerator with the needles pointing ________ to prevent suspended particles from clogging the needle
3 / upward
A clients labor doesnt progress. After ruling out CPD, the doctor orders IV admin of 1,000 ml normal saline w/ Pitocin 10 units to run at 2 miliunits / min. 2 miliunits/min is equivalent to how many ml/unit 1. 0.002 2. 0.02 3. 0.2 4. 2.0
3 = 0.2 each unit of oxytocin contains 1,000 miliunits. Therefore, 1,000 ml of IV fluid contains 10,000 miliunits (10 units) of Pitocin
An adolescent is brought to the facility by friends after accidentally ingesting gasoline while siphoning it from a car. Based on the nurse's knowledge of petroleum distillates, which system should be the priority assessment? 1. GI system 2. Respiratory system 3. Neurologic system 4. Cardiovascular system
2. Respiratory system RATIONALE: The primary concern with petroleum distillate ingestion is its effect on the respiratory system. Aspiration or absorption of petroleum distillates can cause severe chemical pneumonitis and impaired gas exchange. The GI, neurologic, and cardiovascular systems may also be affected if the petroleum contains additives such as pesticides, but the respiratory system is the priority assessment.
Parents of a 5-year-old call the clinic to tell the nurse that they think their child has been abused by her day-care provider. What should the nurse advise them to do? 1. Make an appointment to speak with the day-care provider. 2. Schedule an immediate appointment with their health care provider. 3. Call the child protective services to file a complaint. 4. Talk to their attorney to file charges against the accused.
2. Schedule an immediate appointment with their health care provider. RATIONALE: Because more information needs to be obtained from the child and family, an immediate appointment is most appropriate. It's unclear what type of abuse the parents are concerned about. Calling child protective services is appropriate but isn't the first action to take; neither is talking to an attorney or the day-care provider.
A nurse is reviewing a care plan for a 10-year-old child who has recently been diagnosed with type 1 diabetes. Which instruction should the nurse remove from a teaching plan focusing on proper hygiene? 1. Encourage regular dental care. 2. Teach blood glucose monitoring. 3. Teach care of cuts and scratches. 4. Teach proper foot care.
2. Teach blood glucose monitoring. RATIONALE: Teaching blood glucose monitoring and the use of equipment is necessary in diabetic teaching within a care plan that focuses on demonstrating testing blood glucose levels, not a care plan that focuses on proper hygiene. Encouraging regular dental care, teaching proper care of cuts and scratches, which minimizes the risk of infection, and teaching proper foot care are all appropriate for a teaching plan focusing on proper hygiene for a child with type 1 diabetes.
A nurse provides privacy to the infants in her care. This approach is an example of which international concept? 1. Individualization of nursing care 2. The infant's right to privacy 3. The parental expectation for nursing behavior 4. The hospital's liability protection
2. The infant's right to privacy RATIONALE: All clients are entitled to privacy; providing it doesn't represent individualization of nursing care. Nurses provide privacy to minors without regard to their parents' expectations. Provision of privacy is every client's right and isn't specifically related to institutional liability.
A child's parents state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the parents? 1. Safety latches on kitchen cabinets 2. Toy chest in front of a second-story, locked window 3. Pot handles turned toward the back of the stove 4. Hot water heater temperature set at 120° F (48.9° C) or below
2. Toy chest in front of a second-story, locked window RATIONALE: A toy chest in front of a second-story locked window displays misunderstanding because toddlers are able to climb on low furniture and open windows that may not always be locked, especially in the summer. In such situations, the child could fall out of the window. Keeping child safety latches on kitchen cabinets, turning pot handles toward the back of the stove, and setting the hot water heater at a nonscalding temperature are all safeguards against toddler injury. These safeguards demonstrate full understanding of a toddler's developmental abilities.
A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has: 1. patent ductus arteriosus. 2. coarctation of the aorta. 3. a ventricular septal defect. 4. truncus arteriosus.
2. coarctation of the aorta. RATIONALE: The nurse should suspect coarctation of the aorta because it causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a bounding radial pulse. These signs are rare in patent ductus arteriosus, ventricular septal defect, and truncus arteriosus.
A physician orders penicillin G, 300,000 units I.M., for an 18-month-old child. Where should the nurse administer this injection? 1. Deltoid muscle 2. Vastus lateralis muscle 3. Dorsogluteal muscle 4. Ventrogluteal muscle
2. Vastus lateralis muscle RATIONALE: For a child younger than age 3, the thigh (vastus lateralis muscle) is the best site for I.M. injections because it has few major nerves and blood vessels. The deltoid, dorsogluteal, and ventrogluteal sites aren't recommended for a child younger than age 3 because of the lack of muscle development and the risk of nerve injury during injection. Before the dorsogluteal or ventrogluteal sites can be used safely, the child should have been walking for at least 1 year to ensure sufficient muscle development.
When assessing a child with muscular dystrophy, the nurse expects which finding? 1. Pain 2. Waddling gait 3. Joint swelling 4. Limited range of motion (ROM)
2. Waddling gait RATIONALE: A waddling, wide-based gait is a sign of muscular dystrophy. A nurse wouldn't expect pain, joint swelling, and limited ROM because they are rare with this disease.
A pediatric nurse preceptor working on an oncology floor observes a new graduate crying in the nurses' lounge. The nurse's best action would be to: 1. let the graduate cry and get it out of her system. 2. ask the graduate what's bothering her. 3. ask the graduate if she thinks she can handle being a pediatric nurse. 4. let the nurse-manager know that the new graduate isn't ready for the emotions that working on this unit evokes.
2. ask the graduate what's bothering her. RATIONALE: Caring for acute or chronically ill children can be emotionally and physically stressful. A preceptor to a new nurse should be supportive and empathetic by asking about the new nurse's feelings. It isn't appropriate for the preceptor to make judgments by asking the new nurse if she thinks she can handle being a pediatric nurse, and it isn't acceptable for the preceptor to talk with the nurse-manager about the issue at this time. It isn't unusual for a nurse to need time to emotionally adjust to a new situation or new client population.
A nurse should take action when a healthy 3-month-old infant is: 1. placed in a convertible car seat in a rear-facing position. 2. being fed formula that isn't mixed according to the manufacturer's instructions. 3. sleeping in a cardboard box on the floor of his mother's bedroom. 4. being put to sleep with a pacifier.
2. being fed formula that isn't mixed according to the manufacturer's instructions. RATIONALE: Incorrectly mixed formula can cause an infant to develop severe electrolyte and nutrition imbalances. This safety hazard necessitates immediate attention. Placing a 3-month-old infant in a rear-facing car seat is appropriate. Although an infant sleeping in a cardboard box on the floor may be a concern, it isn't an immediate safety hazard. An infant being put to sleep with a pacifier isn't a safety concern.
A nurse is caring for an adolescent who underwent surgery for a perforated appendix. When caring for this adolescent, the nurse should keep in mind that the main life-stage task for an adolescent is to: 1. resolve conflict with parents. 2. develop an identity and independence. 3. develop trust. 4. plan for the future.
2. develop an identity and independence. RATIONALE: An adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures during the course of development. Adolescents rarely finalize plans for the future; this normally happens later in adulthood.
A 4-year-old child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect: 1. subdural hematoma. 2. epidural hematoma. 3. subarachnoid hemorrhage. 4. concussion.
2. epidural hematoma. RATIONALE: An epidural hematoma is characterized by an initial loss of consciousness followed by transient consciousness leading to unconsciousness. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. As for a concussion, it may result in a brief loss of consciousness.
Before the placenta functions, the corpus luteum is the primary source for synthesis of which of the following hormones? 1. cortisol and thyroxine 2. estrogen and progesterone 3. LH and FSH 4. T4 and T3
2. estrogen and progesterone The CL produces progesterone and estrogen for the 1st 8-10 weeks of pregnancy until the placenta takes over this function. The high levels of estrogen and progesterone cause suppression of LH and FSH. T4 and T3 are produced in the adrenal gland
For a child who's admitted to the emergency department with an acute asthma attack, nursing assessment is most likely to reveal: 1. apneic periods. 2. expiratory wheezing. 3. inspiratory stridor. 4. fine crackles throughout.
2. expiratory wheezing. RATIONALE: Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma rarely causes apneic periods. Inspiratory stridor more commonly accompanies croup. The child may have some fine crackles but wheezing is much more common in an acute asthma attack.
A 13-year-old girl visits the school nurse because she's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the girl may have scoliosis. The nurse should first: 1. send the girl home to recover. 2. inspect the girl for uneven shoulder height or uneven hip height. 3. arrange for the girl to have spinal X-rays as soon as possible. 4. ask the girl's parents to take her to a physician immediately.
2. inspect the girl for uneven shoulder height or uneven hip height. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the girl's parents.
A mother tells the nurse that her preschool-age daughter with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to: 1. bananas. 2. latex. 3. kiwifruit. 4. color dyes.
2. latex. RATIONALE: If a child is sensitive to bananas, kiwifruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.
A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: 1. monitor the child with a pulse oximeter in her office. 2. prepare to ventilate the child. 3. return the child to class. 4. contact the child's parent or guardian.
2. prepare to ventilate the child. RATIONALE: The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child shouldn't be returned to class. When the child's condition allows, the nurse can notify the parents or guardian.
A child is diagnosed with nephrotic syndrome. When planning the child's care, the nurse understands that the primary goal of treatment is to: 1. manage urinary changes by monitoring fluid intake and output and observing for hematuria. 2. reduce the excretion of urinary protein. 3. help prevent cardiac or renal failure by carefully monitoring fluid and electrolyte balance. 4. decrease edema and hypertension through bed rest and fluid restriction.
2. reduce the excretion of urinary protein. RATIONALE: The primary goal of treatment for a child with nephrotic syndrome is to reduce excretion of urinary protein and maintain protein-free urine. Nephrotic syndrome isn't associated with hematuria, cardiac failure, or hypertension. Fluid restriction isn't warranted.
A mother, who is visibly upset, carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse's first action should be: 1. take the infant from the mother and offer to help. 2. take the infant and mother back to a treatment room. 3. call the resuscitation team and the supervisor. 4. call security and the hospital administration.
2. take the infant and mother back to a treatment room. RATIONALE: Taking the infant and mother into a treatment room for assessment is appropriate because this action provides privacy and a controlled environment. Taking the infant away from the mother is inappropriate because the mother should be allowed to remain with her child if she wishes. If she doesn't want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Security isn't warranted in this situation.
Which statement by a mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective? 1. "I know that I'll need to keep my child as quiet as possible." 2. "I just went out and bought all I'll need for the special diet." 3. "I've been checking the urine for protein so I'll be able to do it at home." 4. "I'm sure that my child will be back to normal soon and I won't have to worry about this anymore."
3. "I've been checking the urine for protein so I'll be able to do it at home." RATIONALE: The mother stating that she'll check her toddler's urine for protein indicates effective teaching because such testing helps detect the progression of nephrotic syndrome. The child doesn't need to be kept quiet and usually isn't placed on a specific diet. How the child feels will dictate the child's activity level. Most children return to normal soon but may relapse.
An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters? 1. None because this isn't a safe dosage 2. 0.08 ml 3. 1.08 ml 4. 1.8 ml
3. 1.08 ml RATIONALE: Because the infant weighs 17 lb (7.7 kg), the safe dosage range is 385 to 578 mg daily. The ordered dosage, 540 mg daily, is safe. To calculate the amount to administer, the nurse may use the following fraction method: 500 mg/2 ml = 270 mg/X ml 500X = 270 × 2 500X = 540 X = 540/500 X = 1.08 ml
Which of the following is the recommended immunization schedule for diphtheria, tetanus toxoids, and acellular pertussis (DTaP)? 1. Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 2. 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years 4. Birth, 3 months, 6 months, 12 months, and 4 to 6 years
3. 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years RATIONALE: According to the American Academy of Pediatrics and the Committee on Infectious Diseases, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school).
A nurse is teaching the mother of an infant. The nurse should instruct the mother to introduce her infant to solid foods at what age? 1. 2 months 2. 4 months 3. 6 months 4. 8 months
3. 6 months RATIONALE: Solid foods are typically introduced around age 6 months. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. By age 8 months, the infant usually has been introduced to iron-fortified infant cereal and vegetables and will begin to try fruits.
A nurse expects an infant to sit up without support at which age? 1. 4 months 2. 6 months 3. 8 months 4. 10 months
3. 8 months RATIONALE: Most infants can sit up without support by age 8 months. At age 4 months, the infant can lift the head off the mattress up to a 90-degree angle. Between ages 6 and 7 months, the infant can sit while leaning forward on the hands. At age 10 months, the infant typically can move from a prone to a sitting position and pull himself up to a standing position.
When administering gentamicin (Garamicin) to a preschooler, which monitoring schedule is best for determining the drug's effectiveness? 1. A serum trough level every morning 2. A serum peak level after the second dose 3. A serum trough and peak level around the third dose 4. Serial serum trough levels after three doses (24 hours)
3. A serum trough and peak level around the third dose RATIONALE: Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. A serum peak and trough level (taken half an hour before the dose and half an hour after the dose has been administered) around the third dose is the most accurate way to determine the correct serum values because the third dose provides enough medication buildup in the blood stream to be measured. A trough level every morning, a serum peak level after the second dose, and serial serum trough levels won't provide sufficient data about the effectiveness of the antibiotic.
A nurse is assessing a child who recently received an antibiotic for an ear infection. The mother states that her child seems to have a harder time hearing than before and that the child told her that he hears ringing in his ears. The nurse suspects the child is taking an antibiotic from which class? 1. Cephalosporins 2. Penicillins 3. Aminoglycosides 4. Carbapenems
3. Aminoglycosides RATIONALE: Aminoglycosides have a high risk of ototoxicity, which is indicated by hearing loss and tinnitus. Cephalosporins, penicillins, and carbapenems aren't associated with ototoxicity.
The client at greatest risk for postoperative wound infection is: 1. A 3-month-old infant postoperative from pyloric stenosis repair 2. A 78-year-old postoperative from inguinal hernia repair 3. An 18-year-old drug user postoperative from removal of a bullet in the leg 4. A 32-year-old diabetic postoperative from an appendectomy
3. An 18-year-old drug user postoperative from removal of a bullet in the leg; All are at risk for infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is at great risk for immune deficiency.
To decrease the likelihood of bradyarrhythmias in children during endotracheal intubation, succinylcholine (Anectine) is used with which agent? 1. Epinephrine (Adrenalin) 2. Isoproterenol (Isuprel) 3. Atropine 4. Lidocaine (Xylocaine)
3. Atropine RATIONALE: Succinylcholine is an ultra-short-acting depolarizing agent used for rapid-sequence intubation. Bradycardia can occur, especially in children. Atropine is the drug of choice in treating or preventing succinylcholine-induced bradycardia. Lidocaine is used in adults only. Epinephrine bolus and isoproterenol aren't used in rapid-sequence intubation because of their profound cardiac effects.
For a child with a circumferential chest burn, what is the most important factor for the nurse to assess? 1. Wound characteristics 2. Body temperature 3. Breathing pattern 4. Heart rate
3. Breathing pattern RATIONALE: Breathing pattern is the most important factor to assess because eschar impedes chest expansion in a child with a circumferential chest burn, causing breathing difficulty. Wound characteristics, body temperature, and heart rate are also factors that should be assessed, but they aren't as important as breathing pattern.
An infant undergoes surgery to remove a myelomeningocele. To detect complications as early as possible, the nurse should stay alert for which postoperative finding? 1. Decreased urine output 2. Increased heart rate 3. Bulging fontanels 4. Sunken eyeballs
3. Bulging fontanels RATIONALE: Because an infant's fontanels remain open, the skull may expand in response to increased intracranial pressure, a possible postoperative complication. Decreased urine output and sunken eyeballs (signs of dehydration) and a decrease in heart rate are rarely seen as postoperative complications of myelomenigocele removal.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first? 1. Turn off the infusion pump. 2. Position the child on the side. 3. Clamp the catheter. 4. Flush the catheter with heparin.
3. Clamp the catheter. RATIONALE: First, the nurse must clamp the catheter to prevent air entry, which could lead to air embolism. If an air embolism occurs, the nurse should position the child on the side after clamping the catheter. The nurse may turn off the infusion pump after ensuring the child's safety. If blood has backed up in the catheter, the nurse may need to flush the catheter with heparin; however, this isn't the initial priority.
When meeting with a family who'll learn that their 3-year-old is seriously ill, which action demonstrates the nurse's role as collaborator of care? 1. Providing the parents with information about financial assistance programs. 2. Informing the family of the diagnosis and recently discovered findings. 3. Coordinate the multidisciplinary services and providing information about them. 4. Referring and consulting with other specialties to help in treating the diagnosis.
3. Coordinate the multidisciplinary services and providing information about them. RATIONALE: Coordinating the multidisciplinary services and providing information about them demonstrate collaboration because the nurse will be explaining the functions of social service, case management, and so forth. Providing parents with information about financial assistance programs is the responsibility of social services, not a nursing role. Informing the family of the diagnosis and recently discovered findings is a physician's responsibility as is referring and consulting with other specialties.
A nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority? 1. Changing the linens on the clients' beds 2. Restocking the bedside supplies needed for a dressing change on the upcoming shift 3. Documenting the care provided during her shift 4. Emptying the trash cans in the assigned client rooms
3. Documenting the care provided during her shift RATIONALE: Documentation should take top priority because it's the only way the nurse can legally claim that interventions were performed. Changing linens, restocking supplies, and emptying trash cans would be appreciated by the nurses on the oncoming shift but aren't mandatory and don't take priority over documentation.
An 8-year-old child is refusing to have a scheduled appendectomy even though his parents have given informed consent for the surgery. Which action is most appropriate for the nurse to take? 1. Cancel the surgery until the child gives informed consent. 2. Explain the surgery in detail, telling the child that he might die if he doesn't have the operation. 3. Explore the child's knowledge of the procedure and his prior experiences with surgery. 4. Assure the child that other children have had the surgery and have done very well postoperatively.
3. Explore the child's knowledge of the procedure and his prior experiences with surgery. RATIONALE: By exploring the child's knowledge of the procedure and his prior experiences with surgery, the nurse may be better able to identify the etiology of his feelings about the procedure. Children can't provide informed consent; parents or guardians do so. Explaining the surgical procedure in detail and informing the child that he could die if he doesn't have the surgery would probably make him more fearful. Telling the child that other children have had the surgery and have done well offers false reassurance.
A nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent? 1. Anxiety related to separation from parents 2. Fear related to the unknown 3. Fear related to altered body image 4. Ineffective coping related to activity restrictions
3. Fear related to altered body image RATIONALE: Fear related to altered body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent, eliminating a diagnosis of Anxiety related to separation from parents. Adolescents may have Fear related to the unknown, but they typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent.
An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks him to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? 1. Grapefruit and white toast 2. Pancakes and a banana 3. Ham and eggs 4. Bagel and cream cheese
3. Ham and eggs RATIONALE: Good sources of dietary iron include red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables. Fresh fruits and milk products contain only small amounts of iron. White bread isn't a good iron source.
According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old child? 1. Intimacy versus isolation 2. Trust versus mistrust 3. Industry versus inferiority 4. Identity versus role confusion
3. Industry versus inferiority RATIONALE: According to Erikson, an 11-year-old child is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old child because the child may not be able to accomplish tasks, which prevents him from achieving a sense of industry. Intimacy is the developmental task of a young adult. Trust is the developmental task to be achieved during infancy. Identity is the developmental task of adolescence.
Which nursing diagnosis is the most appropriate for a preschool child with epiglottiditis? 1. Anxiety related to separation from parent 2. Decreased cardiac output related to bradycardia 3. Ineffective airway clearance related to laryngospasm 4. Impaired gas exchange related to noncompliant lungs
3. Ineffective airway clearance related to laryngospasm RATIONALE: Ineffective airway clearance related to laryngospasm is the most appropriate nursing diagnosis for a preschool child with epiglottiditis because complete upper airway obstruction may occur suddenly and be precipitated by improper examination or intervention. The upper airway obstruction is the result of laryngospasm and edema. Anxiety related to separation from parent isn't an appropriate nursing diagnosis because the client is likely anxious because of respiratory distress. The nurse should allow the parent to stay with the child and should encourage the parent to hold and reassure the child. The child will probably be tachycardic, not bradycardic until respiratory failure ensues. The child has impaired gas exchange from impeded airflow, not from a noncompliant lung.
An 8-year-old child is suspected of having meningitis. Signs of meningitis include: 1. Cullen's sign. 2. Koplik's spots. 3. Kernig's sign. 4. Chvostek's sign.
3. Kernig's sign. RATIONALE: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign, the client is in the supine position with knees flexed; a leg is then flexed at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can't be extended and attempts to extend the knee result in pain. Cullen's sign is the bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. Koplik's spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. A calcium deficit is suggested if the facial muscles twitch.
A mother of a preschooler recently diagnosed with type 1 diabetes makes an urgent call to the pediatrician's office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to rouse. The nurse should instruct the mother to take which action first? 1. Obtain a urine sample and measure the glucose level. 2. Force the child to drink orange juice. 3. Measure the child's blood glucose level. 4. Call 911 because this situation is an emergency.
3. Measure the child's blood glucose level. RATIONALE: In a child with type 1 diabetes, behavioral changes may signal either hypoglycemia or hyperglycemia. Measuring the blood glucose level is the only way to determine which condition is present and, therefore, should be the mother's first action. Urine glucose measurement doesn't accurately reflect the current blood glucose level. Forcing a lethargic child to drink fluids could cause aspiration. After measuring the child's blood glucose level, the mother may need to take additional emergency measures such as administering insulin or a simple glucose source. If the child doesn't respond to these measures, she may need to call for emergency help.
46. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."
3. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.
Parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate? 1. Caloric requirements per kilogram of body weight increase slightly during the preschool-age period. 2. The preschooler's nutritional requirements differ greatly from those of a toddler. 3. The quality of food that a preschooler consumes is more important than the quantity. 4. Protein should account for 25% of the preschooler's total caloric intake.
3. The quality of food that a preschooler consumes is more important than the quantity. RATIONALE: Stating that food quality is more important than quantity is most accurate because a high caloric intake may include many empty calories. The preschooler's caloric requirement is slightly lower than the toddler's. Overall, however, the preschooler's nutritional requirements are similar to a toddler's. The preschooler requires 1.5 g/kg of protein daily, satisfied by two meat servings, three milk servings, four bread servings, and four fruit and vegetable servings.
An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: 1. increased myelination. 2. intracranial hypotension. 3. cerebral hyperemia. 4. a slightly thicker cranium.
3. cerebral hyperemia. RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension — not hypotension — places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable than an adult's, causing the child to receive a more severe injury.
How many weeks equal a termed pregnancy?
38 to 42 weeks
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? 1. "I told my husband to give my son aspirin for his fever." 2. "I'll ask the physician about giving the baby an immunization shot." 3. "I don't have to worry because I've had the measles." 4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." RATIONALE: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.
A parent asks the nurse for advice on disciplining a 3-year-old child. Which statement made by a parent indicates understanding of accepted discipline techniques? 1. "I don't think children younger than 5 understand the purpose of time-out." 2. "My husband uses one form of punishment and I use a different form." 3. "I don't listen to excuses." 4. "We try to be united and consistent in our approach to discipline."
4. "We try to be united and consistent in our approach to discipline." RATIONALE: To deal with misbehavior most successfully, parents should be firm and consistent when taking appropriate disciplinary action. Usually, parents should begin setting limits and implementing discipline, such as using time-outs for inappropriate behavior, around age 1, or when the child begins to crawl and explore the environment. Rigidly enforcing rules wouldn't allow the development of autonomy and could lead to self-doubt. The parent should never be encouraged to withdraw attention or affection as a result of the child's behavior, or any other reason.
A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response is most appropriate? 1. "Some of the staff members don't want to talk to you because you might yell at them." 2. "Why do you seem so angry today? It makes it hard for us to help you." 3. "Is this your normal behavior or are you acting out because your child is hospitalized?" 4. "You seem upset. Having your child hospitalized must be difficult."
4. "You seem upset. Having your child hospitalized must be difficult." RATIONALE: Acknowledging the mother's feelings and recognizing that it's difficult to cope with a hospitalized child allows the mother to express her feelings. Telling the mother that other staff members don't want to talk to her isn't therapeutic. Asking her to explain her behavior places the mother on the defensive and also isn't therapeutic.
Which of the following doses of Rh immune globulin RhoGAM is appropriate for a pregnant client at 28 weeks gestation? 1. 50 mcg in a sensitized client 2. 50 mcg in an unsensitized client 3. 300 mcg in a sensitized client 4. 300 mcg in a unsensitized client
4. 300 mcg in a unsensitized client An Rh negative unsensitized woman should be given 300 mcg of RhoGAM at 28 weeks after an indirect Coombs test is done to verify that sensitization hasn't occurred. For a 1st trimester abortion or ectopic pregnancy, 50 mcg of RhoGAM is given.
A 16-year-old adolescent sustains a severe head injury in a motor vehicle accident. He's admitted to the neurologic unit and subsequently develops neurogenic diabetes insipidus. The physician orders vasopressin (Pitressin), 5 units subcutaneously (subQ) twice per day. How long will the effects of the vasopressin last? 1. 5 minutes 2. 30 minutes 3. 1 hour 4. 4 hours
4. 4 hours RATIONALE: The duration of action for vasopressin administered subQ is 2 to 8 hours.
A nurse has just received a report from the nurse who worked the previous shift. Which child should she assess first? 1. A 5-year-old child who needs factor VIII before a tonsillectomy 2. A 4-year-old child admitted with reactive airway disease receiving proventil (Albuterol) every 4 hours 3. A 3-year-old child who had an appendectomy and is complaining of pain 4. A 6-year-old child with acute heart failure on 2 L of oxygen
4. A 6-year-old child with acute heart failure on 2 L of oxygen RATIONALE: Following the ABCs (airway, breathing, and circulation), the nurse should assess the child on oxygen first to make sure the child has the oxygen in place and the pulse oximeter reading is above 94%. The other children should be assessed as soon as possible, but the child on oxygen takes priority.
When teaching a mother of a 17-month-old about toilet training, which instruction would initially be most appropriate? 1. Place the toddler on the potty chair every 2 hours for 10 minutes. 2. Offer a reward every time the child has a bowel movement in the potty chair. 3. Remove the diaper and use training pants to begin the process. 4. Be sure the child is ready before starting to toilet train.
4. Be sure the child is ready before starting to toilet train. RATIONALE: All of the instructions are appropriate, but knowing whether the child is ready to toilet train is initially most appropriate. Many 17-month-olds don't have the neuromuscular control to be able to be trained. Waiting a few more months until the child is closer to age 2 years allows the child to develop more control. The mother should be taught the signs of readiness for toilet training.
A nurse is developing a teaching plan for a child with acute poststreptococcal glomerulonephritis. What is the most important point to address in this plan? 1. Infection control 2. Nutritional planning 3. Prevention of streptococcal pharyngitis 4. Blood pressure monitoring
4. Blood pressure monitoring RATIONALE: Because poststreptococcal glomerulonephritis may cause severe, life-threatening hypertension, it is most important for the nurse to teach the parents how to monitor the child's blood pressure. Infection control, nutritional planning, and prevention of streptococcal pharyngitis are important but are secondary to blood pressure monitoring.
An adolescent with ulcerative colitis who is taking corticosteroids is at risk for which complication? 1. Jaundice 2. Decreased bowel sounds 3. Perianal lesions 4. Delayed sexual maturation
4. Delayed sexual maturation RATIONALE: In children and adolescents with ulcerative colitis, frequent diarrhea and poor nutrient absorption from the bowel lead to malnutrition. Nausea, vomiting, and anorexia may further compromise nutritional status. Malnutrition, in turn, may cause growth retardation and delayed sexual maturation. Corticosteroid therapy, which is commonly used to treat ulcerative colitis, may also cause growth retardation and delayed sexual maturation. Jaundice isn't associated with ulcerative colitis. Because this disease causes increased bowel motility, bowel sounds may be hyperactive, not decreased. Perianal lesions are rare in clients with ulcerative colitis.
A child, age 15 months, is recovering from surgery to remove a Wilms' tumor. Which finding best indicates that the child is free from pain? 1. Decreased appetite 2. Increased heart rate 3. Decreased urine output 4. Increased interest in play
4. Increased interest in play RATIONALE: A behavioral change is one of the most valuable clues to pain. A child who's pain-free likes to play. In contrast, a child in pain is less likely to play or to consume food or fluids. An increased heart rate may indicate increased pain. Decreased urine output may signify dehydration.
Which behavior exhibited by parents of a chronically ill child may indicate feelings of guilt about the child's illness? 1. Anger 2. Sadness 3. Shock 4. Overindulgence
4. Overindulgence RATIONALE: Parents who feel guilty about a child's illness may overindulge the child. Anger, sadness, and shock are common in parents of chronically ill children but don't necessarily indicate feelings of guilt.
A toddler is admitted to the facility for treatment of a severe respiratory infection. The child's recent history includes fatty stools and failure to gain weight steadily. The physician diagnoses cystic fibrosis. By the time of the child's discharge, the child's parents must be able to perform which task independently? 1. Allergy-proofing the home 2. Maintaining the child in an oxygen tent 3. Maintaining the child on a fat-free diet 4. Performing postural drainage
4. Performing postural drainage RATIONALE: The child with cystic fibrosis is at risk for frequent respiratory infections secondary to increased viscosity of mucus gland secretions. To help prevent respiratory infections, caregivers must perform postural drainage several times daily to loosen and drain secretions. Because exocrine gland dysfunction, not an allergic response, causes bronchial obstruction in cystic fibrosis, allergy-proofing the home isn't necessary. Oxygen therapy may be indicated, but only during acute disease episodes. Also, such therapy must be supervised closely; home oxygen therapy is inappropriate because chronic hypoxemia poses the risk of oxygen toxicity. If steatorrhea can't be controlled, the child should reduce, but not eliminate, dietary fat intake.
A 2½-year-old child is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation? 1. Prone 2. Left lateral 3. Supine 4. Right lateral
4. Right lateral RATIONALE: The toddler should be positioned on his right side because gravity contributes to increased blood flow to the right lung, thereby allowing for better gas exchange. Positioning the child prone, supine, or in the left lateral position doesn't allow for better gas exchange in this child.
Which safeguard should a nurse employ with I.V. fluid administration for an infant? 1. Administration of fluid at the slowest possible rate 2. Use of a gravity infusion set 3. Use of a small I.V. infusion set 4. Use of an infusion pump to regulate the flow rate
4. Use of an infusion pump to regulate the flow rate RATIONALE: Use of an infusion pump to regulate the flow rate is the appropriate safeguard because infants and children with compromised cardiopulmonary status are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a small I.V. infusion set won't protect against fluid overload when I.V. administration is too rapid.
Which intervention provides the most accurate information about an infant's hydration status? 1. Monitoring the infant's vital signs 2. Accurately measuring intake and output 3. Monitoring serum electrolyte levels 4. Weighing the infant daily
4. Weighing the infant daily RATIONALE: Weighing an infant daily provides the most accurate information about the infant's hydration status. Vital signs, intake and output, and electrolyte levels provide helpful information about an infant's hydration status, but they aren't as accurate as weighing daily.
When assessing a child's cultural background, the nurse should keep in mind that: 1. cultural background usually has little bearing on a family's health practices. 2. physical characteristics mark the child as part of a particular culture. 3. heritage dictates a group's shared values. 4. behavioral patterns are passed from one generation to the next.
4. behavioral patterns are passed from one generation to the next. RATIONALE: The nurse should keep in mind that a family's behavioral patterns and values are passed from one generation to the next. Cultural background commonly plays a major role in determining a family's health practices. Physical characteristics don't indicate a child's culture. Although heritage plays a role in culture, it doesn't dictate a group's shared values, and its effect on culture is weaker than that of behavioral patterns.
A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 2 minutes of CPR, the nurse finds he still isn't breathing and has no pulse. The nurse should then: 1. resume CPR beginning with breaths. 2. declare her efforts futile and stop CPR. 3. resume CPR beginning with chest compressions. 4. call for assistance.
4. call for assistance. RATIONALE: After 2 minutes of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
A nurse may use the performance improvement process to determine underlying causes and contributing factors related to sentinel events by: 1. randomly observing client care without advance warning. 2. evaluating a single incident that resulted in an unanticipated outcome. 3. requesting that a documented expert in the field perform a review. 4. conducting root cause analysis.
4. conducting root cause analysis. RATIONALE: Root cause analysis is used to gather information about factors that contribute to a problem (root causes) so that the nurse can identify ways to correct the problem. Random observation doesn't necessarily produce data to explain a specific sentinel event. Evaluation of a single incident rarely identifies underlying causes and contributing factors to sentinel events. An expert consultation doesn't necessarily reveal site-specific underlying causes and contributing factors in an individual health care facility.
A neonate has been diagnosed with caput succedaneum. which statement is true? 1. usually resolves in 3-6 weeks 2. collection of blood btw/ skill and periosteum 3. doesnt cross the cranial suture line 4. it involves swelling of the tissue over the presenting part of the head
4. it involves swelling of the tissue over the presenting part of the head due to sustained pressure this boggy edematous swelling is present at birth, CROSSES the suture line occurs in occipital area a cephalohematoma is a collection of blood btw/ the skill and periosteum that DOESNT cross the suture lines and resolves in 3-6 weeks caput seccedaneum resolves within 3-4 DAYS
Which Sx would indicate the neonate was adapting approp to extrauterine life w/out difficulty? 1. nasal flare 2. light audible grunting 3. resp rate 40-60 breaths/min 4. resp rate 60-80 breaths/min
4. resp rate of 40-60 breaths/min is normal for a neonate during the transitional period nasal flaring, resp rate > 60 and audible grunting = SIGNS OF RESP DISTRESS!
A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. The school should be informed that: 1. these students are too young to screen; instead, older students should be screened. 2. these students are too old to screen and will no longer benefit from screening for scoliosis. 3. scoliosis screening requires sophisticated equipment and can't be done in school. 4. this is an appropriate request and arrangements will be made as soon as possible.
4. this is an appropriate request and arrangements will be made as soon as possible. RATIONALE: The school's request is appropriate because screening for scoliosis should begin at age 8 and be performed yearly thereafter. Also, because screening for scoliosis involves inspection of the spine and use of a scoliometer, both can be done in a school setting.
During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action? A. Assess femoral pulses B. Obtain a bladder scan C. Measure the abdominal circumference D. Ask the patient to perform a Valsalva maneuver
A
A client's electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is: A) Normal sinus rhythm B) Sinus bradycardia C) Sinus tachycardia D) Sinus dysrhythmia
A) Normal sinus rhythm
Which of the following results is the primary treatment goal for angina? A) Reversal of ischemia B) Reversal of infarction C) Reduction of stress and anxiety D) Reduction of associated risk factors
A) Reversal of ischemia Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption and increasing oxygen supply. An infarction is permanent and can't be reversed.
The nurse cautions the client receiving isosorbide dinitrate for treatment of angina that long-term use can lead to the development of: A) Tolerance. B) Tachycardia. C) Hypotension. D) Urinary retention.
A) Tolerance.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patient's room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.
ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.
A client with a myocardial infarction is admitted to the cardiac unit. The nurse can best determine the effectiveness of the client's ventricular contractions by: A) OBSERVING ANXIETY LEVELS B) EVALUATING ENZYME RESULTS C) MONITORING URINARY OUTPUT HOURLY D) ASSESSING BREATH SOUNDS FREQUENTLY
C) MONITORING URINARY OUTPUT HOURLY
The teaching plan for a client being started on long-acting nitroglycerin includes the action of this drug. The nurse teaches that this drug relieves chest pain by which action? A) Dilating just the coronary arteries B) Decreasing the blood pressure C) Increasing contractility of the heart D) Dilating arteries and veins
D) Dilating arteries and veins
What do alpha cells release?
Glucagon
Hypersonmolar hyperglycemic nonketosis coma (HHNKC) is normally seen in Type __ Diabetes.
I (DKA seen most commonly)
When assessing an infant for changes in intracranial pressure (ICP), a nurse must palpate the fontanels. Identify the area where the nurse should palpate to assess the anterior fontanel.
RATIONALE: The anterior fontanel is formed by the junction of the sagittal, frontal, and coronal sutures. It's shaped like a diamond and normally measures 4 to 5 cm at its widest point. A widened, bulging fontanel is a sign of increased ICP.
After a child has a cardiopulmonary arrest, which drug would the nurse expect to administer? 1. Dopamine (Inocor) 2. Epinephrine 3. Sodium bicarbonate 4. Atropine
RATIONALE: After successful resuscitation, dopamine would be given as an infusion to increase cardiac output and maintain blood pressure. Epinephrine, sodium bicarbonate, and atropine are first-round drugs that are used during a cardiopulmonary arrest.
A nurse is performing cardiopulmonary resuscitation (CPR) on an infant. Identify the area where the nurse should assess for a pulse.
RATIONALE: The brachial pulse should be assessed when performing infant CPR. The carotid pulse, which is used in children and adults, is extremely difficult to locate in an infant because of his short neck.
A nurse and a nursing assistant are caring for a group of adolescents. Which task could the nurse safely delegate to the nursing assistant? 1. Helping a girl into a wheelchair 2. Administering acetaminophen (Tylenol) for a fever 3. Assisting a physician during the first postoperative dressing change 4. Reviewing discharge instructions for an adolescent recently diagnosed with diabetes
RATIONALE: Moving a client into a wheelchair is within the scope of practice of the nursing assistant. Only licensed personnel are authorized to administer medications. A registered nurse should personally assess the client's surgical wound so she can monitor for adverse changes. Also, the registered nurse should provide adequate client education about a newly diagnosed disease to ensure complete compliance; the nursing assistant may not have the knowledge to do so.
Which vaccine can not be given during pregnancy?
Rubella
Diabetics are prone to CAD because _______ destroys cells just like _____
Sugar destroys vessels just like fat.
The nurse is preparing to discharge a patient who is prescribed ibuprofen the nurse knows that more teaching is required when
When the client states their blood pressure won't change
A 10-year-old child visits the pediatrician's office for his annual physical examination. When the nurse asks how he's doing, he becomes quiet and states that his grandmother died last week. A child this age is likely to make which statements about the concept of death? Select all that apply. 1. "Once you die you never come back." 2. "All people must die." 3. "My grandmother's death has been hard to understand." 4. "My grandmother died because she was sick and nothing could make her better." 5. "My grandmother is dead, but she'll come back." 6. "My grandmother died because someone in the family did something bad."
`1. "Once you die you never come back." 3. "My grandmother's death has been hard to understand." 4. "My grandmother died because she was sick and nothing could make her better." RATIONALE: By age 10, most children know that death is irreversible and final. However, a child may still have difficulty understanding the specific death of a loved one. School-age children should be able to identify cause-and-effect relationships, such as when a terminal illness causes someone to die. Adolescents, not school-age children, understand that death is a universal process. Preschoolers see death as temporary and may think of death as a punishment.
The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? a) Pulse rate of 72/minute b) Temperature of 98.4° F c) Oxygen saturation 96% d) Respiratory rate of 18/minute
a) Pulse rate of 72/minute Correct Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 indicates that the patient did not experience tachycardia as an adverse effect.
A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? a) Oxygen tent b) Venturi mask c) Nasal cannula d) Oxygen-conserving cannula
b) Venturi mask The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.
What causes hypoglycemia?
peak of insulin amung anything that causes blood sugar to be low.
Reg insulin is _______
clear
Which statement made by the client demonstrates a need for further instruction regarding the use of nitroglycerin? a. "If I get a headache, I should keep taking nitroglycerin and use Tylenol for pain relief." b. "I should keep my nitroglycerin in a cool, dry place." c. "I should change positions slowly to avoid getting dizzy." d. "I can take up to five tablets at 3-minute intervals for chest pain if necessary."
d. "I can take up to five tablets at 3-minute intervals for chest pain if necessary."
complex carbohydrates found in whole ______ and _____________ are preferred over those found in starch-heavy foods, such as pastas because they are longer to digest causing glucose from these type of carbs to be released slowly in the blood preventing a sudden rise in serum glucose level.
grains / vegetables
Eat before exercising to prevent _________
hypoglycemia
have a bedtime snack especially if taking insulin snacks to prevent ________ while asleep
hypoglycemia
Avoid areas above ________ that will be used for exercise during the day or where heat will be applied as it will cause more rapid ___________
muscles / absorbtion
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis? 1. The client assists as much as possible in his care, demonstrating increased participation over time. 2. The client allows the nurse to complete his care in an efficient manner without interfering. 3. The client allows his wife to assume total responsibility for his care. 4. The client allows his wife to complete his care to promote feelings of usefulness.
1. The client's assisting as much as possible in his care and increasing participation over time indicate that the client has accomplished self-care by gaining a sense of control. If the client lets the nurse complete his care without interfering, his behavior would indicate passivity, possibly from denial or depression. If the client allows his wife to assume total responsibility for his care or to complete his care, he still has a self-care deficit and a successful outcome has not been reached.
When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information? 1. Fifth disease is transmitted by respiratory secretions. 2. Fifth disease has an unknown transmission mode. 3. Fifth disease is transmitted by respiratory secretions, stool, and urine. 4. Fifth disease is transmitted by stool.
1. Fifth disease is transmitted by respiratory secretions. RATIONALE: Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.
The most common signs and symptoms of leukemia related to bone marrow involvement are which of the following? A. Petechiae, fever, fatigue B. Headache, papilledema, irritability C. Muscle wasting, weight loss, fatigue D. Decreased intracranial pressure, psychosis, confusion
Answer A is Correct. Signs of infiltration of the bone marrow are petechiae from lowered platelet count, fever related to infection from the depressed number of effective leukocytes, and fatigue from the anemia.
2. A patient who has been told by the health care provider that the cells in a bowel tumor are poorly differentiated asks the nurse what is meant by "poorly differentiated." Which response should the nurse make? a. "The cells in your tumor do not look very different from normal bowel cells." b. "The tumor cells have DNA that is different from your normal bowel cells." c. "Your tumor cells look more like immature fetal cells than normal bowel cells." d. "The cells in your tumor have mutated from the normal bowel cells."
C Rationale: An undifferentiated cell has an appearance more like a stem cell or fetal cell and less like the normal cells of the organ or tissue. The DNA in cancer cells is always different from normal cells, whether the cancer cells are well differentiated or not. All tumor cells are mutations form the normal cells of the tissue.
11. Which action by a nursing assistant (NA) caring for a patient with a temporary radioactive cervical implant indicates that the RN should intervene? a. The NA places the patient's bedding in the laundry container in the hallway. b. The NA flushes the toilet once after emptying the patient's bedpan. c. The NA stands by the patient's bed for an hour talking with the patient. d. The NA gives the patient an alcohol-containing mouthwash for oral care. .
C Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated
The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? a) "Avoid shaking the inhaler before use." b) "Breathe out slowly before positioning the inhaler." c) "Using a spacer should be avoided for this type of medication." d) "After taking a puff, hold the breath for 30 seconds before exhaling."
"Breathe out slowly before positioning the inhaler." It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.
A client has wound that is healing by secondary intention. To best support the healing of the wound, the nurse should expect the practitioner's order to state, "Clean wound with:"
"Clean wound with normal saline and apply a wet-to-damp dressing"; Cleaning with normal saline will not damage fibroblasts. Wet-to-damp dressings allow epidermal cells to migrate more rapidly across the wound surface than dry dressings, thereby facilitating wound healing.
The nurse presents a seminar on HIV testing to a group of seniors and their caregivers in an assisted living facility. Which responses fit the Centers for Disease Control and Prevention's (CDC's) recommendations for HIV testing? (Select all that apply.) A) ''I am 78 years old and I was treated and cured of syphilis many years ago.'' B) ''In 1986, I received a transfusion of platelets.'' C) ''Seven years ago, I was released from a penitentiary.'' D) ''I used to smoke marijuana 30 years ago, but I have not done any drugs since.'' E) ''I had sex with a man with a disreputable past from New York back in the late 1960s, but I have been happily married since 1971.'' F) ''At 68, I am going to get married for the fourth time.''
(A, C, F) A) ''I am 78 years old and I was treated and cured of syphilis many years ago.'' Rationale: People who have had sexually transmitted diseases should be tested for HIV. C) ''Seven years ago, I was released from a penitentiary.'' Rationale: HIV testing is recommended for people who are or have been in jails or prisons. F) ''At 68, I am going to get married for the fourth time.'' Rationale: People who are planning to get married should be tested for HIV.
The home health nurse is making an initial home visit to the client currently living with family members after being hospitalized with pneumonia and newly diagnosed with AIDS. Which statement by the nurse best acknowledges the client's fear of discovery by his family? A) ''Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?'' B) ''Is there somewhere private in the home we can go and talk?'' C) ''I hope that all of your family members know about your disease and how you need to be protected, since you have been so sick.'' D) ''It is your duty to protect your family members from getting AIDS.''
(B) B) ''Is there somewhere private in the home we can go and talk?'' Rationale: A nonthreatening approach initially to find out whether the client has informed family members or desires privacy is very important.
Which statement made to the nurse by a health care worker assigned to care for the client with HIV indicates a breach of confidentiality and requires further education by the nurse? A) ''I told the family members they needed to wash their hands when they enter and leave the room.'' B) ''The other health care worker and I were out in the hallway discussing how we were concerned about getting HIV from our client, so no one could hear us in the client's room.'' C) ''Yes, I understand the reasons why I have to wear gloves when I bathe my client.'' D) ''The client's spouse told me she got HIV from a blood transfusion.''
(B) B) ''The other health care worker and I were out in the hallway discussing how we were concerned about getting HIV from our client, so no one could hear us in the client's room.'' Rationale: Discussing this client's illness outside the client's room is a breach of confidentiality.
The nurse is instructing an unlicensed health care worker on the care of the client with HIV who also has active genital herpes. Which statement by the health care worker indicates effective teaching of standard precautions? A) ''I need to know my HIV status, so I must get tested before caring for any clients." B) ''Putting on a gown and gloves will cover up the itchy sores on my elbows.'' C) ''Washing my hands and putting on a gown and gloves is what I must do before starting care.'' D) ''I will wash my hands before going into the room, and then put on gown and gloves only for direct contact with the client's genitals."
(C) C) ''Washing my hands and putting on a gown and gloves is what I must do before starting care.'' Rationale: Standard precautions include whatever personal protective equipment (PPE) is necessary for the prevention of transmission of HIV and genital herpes.
Which interventions does the home health nurse teach to family members to reduce confusion in the client diagnosed with AIDS dementia? (Select all that apply.) A) Report any behavior changes. B) Use the Glasgow Coma Scale on a daily basis. C) Change the decorations in the home according to the season. D) Put the bed close to the window. E) Write out all instructions and have the client read them over before performing a task. F) Ask the client when he or she wants to shower or bathe. G) Mark off the days of the calendar, leaving open the current date. H) For continuity, the primary caregiver should be the only person reorienting the client.
(C, D, F, G) C) Change the decorations in the home according to the season. Rationale: Seasonal decorations in the home helps with maintaining orientation. D) Put the bed close to the window. Rationale: This allows the client to visualize seasonal and weather changes and assists in orientation. F) Ask the client when he or she wants to shower or bathe. Rationale: Involving the client in planning the daily schedule helps with orientation. G) Mark off the days of the calendar, leaving open the current date. Rationale: Using calendars and crossing off past dates helps with orientation.
The nurse and licensed practical nurse (LPN) are caring for clients on an oncology floor. Which client should not be assigned to the LPN? 1.The client newly diagnosed with chronic lymphocytic leukemia. 2.The client who is four (4) hours post-procedure bone marrow biopsy. 3.The client who received two (2) units of PRBCs on the previous shift. 4.The client who is receiving multiple intravenous piggyback medications
(CORRECT: 1) The newly diagnosed client will need to betaught about the disease and about treat-ment options. The registered nurse cannot delegate teaching to a an LPN.
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. 2. The HIV virus can be eradicated from the host body with the correct medical regimen. 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.
*1. Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.* 2. "Eradicated" means to be completely cured or done away with. HIV cannot be eradicated. 3. The HIV virus originated in the green monkey, in whom it is not deadly. HIV in humans replicates readily using the CD4 cells as reservoirs. 4. The HIV virus uses the CD4 cells of the immune system as reservoirs to replicate itself. TEST-TAKING HINT: If the test taker is not aware of the definition of a word, the individual monitoring the test may be able to define the word, but this is not possible on the NCLEX-RN examination. Of the answer options, option "1" has the most important information regarding prognosis and potential spread to noninfected individuals.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention? 1. Assess the client's body weight and ask what the client has been able to eat. 2. Place in contact isolation and don a mask and gown before entering the room. 3. Check the HCP's orders and determine what laboratory tests will be done. 4. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
*1. The client has a malnutrition syndrome. The nurse assesses the body and what the client has been able to eat.* 2. Standard Precautions are used for clients diagnosed with AIDS, the same as for every other client. 3. The nurse should check the orders but not before assessing the client. 4. The client will probably be placed on total parenteral nutrition and will need to be taught these things, but this is not the first action.
Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A. Bathe in cold water. B. Wear cotton gloves when cooking. C. Consume a diet high in fiber. D. Make sure shoes are snug
. C. Consume a diet high in fiber. A high-fiber diet will assist with constipation due to neuropathy. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.
A nurse is preparing to administer I.V. methylprednisolone sodium succinate (Solu-Medrol) to a child who weighs 44 lb. The order is for 0.03 mg/kg I.V. daily. How many milligrams should the nurse prepare? Record your answer using one decimal place. Answer: milligrams
0.6 milligrams RATIONALE: To perform this dosage calculation, the nurse should first convert the child's weight to kilograms: 44 lb ÷ 2.2 kg/lb = 20 kg Then she should use this formula to determine the dose: 20 kg × 0.03 mg/kg = X mg X = 0.6 mg
Which of the following findings yields a poor prognosis for a pediatric patient with leukemia? " 1) Presence of a mediastinal mass 2) Late CNS leukemia 3) Normal WBC count at diagnosis 4) Disease presents between age 2 and 10
1) Presence of a mediastinal mass indicates a poor prognosis. The rest of the choices refer to diagnosis not prognosis.
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. 1. The drug can be used if the person is allergic to aspirin. 2. Acetaminophen does not affect platelet aggregation. 3. This drug causes little or no gastric distress. 4. Acetaminophen exerts a strong anti-inflammatory effect. 5. The client should have the International Normalized Ratio (INR) checked regularly.
1, 2, 3. Acetaminophen is an alternative for a client who is allergic to aspirin. It does not affect platelet aggregation and the client does not need to have coagulation studies (such as INR). Acetaminophen causes little or no gastric distress. Acetaminophen exerts no anti-inflammatory effects.
Which of the following items are used to perform wound care irrigation? Select all that apply. 1. Clean gloves 2. Sterile gloves 3. Refrigerated irrigating solution 4. 60-mL syringe
1, 2, and 4; To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not refrigerated.
Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed
1, 3, & 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.
Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? 1. Acute respiratory distress syndrome. 2. Migraine-like headaches. 3. Numbness in the right leg. 4. Muscle spasms in the right thigh.
1. Fat emboli usually result in symptoms of acute respiratory distress syndrome, such as apprehension, chest pain, cyanosis, dyspnea, tachypnea, tachycardia, and decreased partial pressure of arterial oxygen resulting from poor oxygen exchange. Migraine-like headaches are not a symptom of a fat embolism, but mental confusion, memory loss, and a headache from poor oxygen exchange may be seen with central nervous system involvement. Numbness in the right leg is a peripheral neurovascular response that most likely is related to the femoral fracture. Muscle spasms in the right thigh are a symptom of a neuromuscular response affecting the local muscle around the femoral fracture site.
A client has a Pearson attachment on the traction setup. Which of the following is the purpose of this attachment? 1. To support the lower portion of the leg. 2. To support the thigh and upper leg. 3. To allow attachment of the skeletal pin. 4. To prevent flexion deformities in the ankle and foot.
1. The Pearson attachment supports the lower leg and provides increased stability in the overall traction setup. It also makes it easier to maintain correct alignment. It does not support the thigh and upper leg or prevent flexion deformities in the ankle and foot. It is not attached to the skeletal pin.
The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client: 1. "You can sit up whenever you want." 2. "You must lie flat on your back most of the time." 3. "You can turn your body." 4. "You must lie on your stomach."
1. The client can sit up in bed, remaining in the supine position so that an even, sustained amount of traction is maintained under the bandage used in the Buck's traction. Maintenance of even, sustained traction decreases the chance that the bandage or traction strap might slip and cause compression or stress on the nerves or vascular tracts, resulting in permanent damage. The client does not have to remain flat but may adjust the head of the bed to varying degrees of elevation while remaining in the supine position. The client should not turn his body to another position because the bandage may slip.
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following? 1. Signs of skin pressure in the groin area. 2. Evidence of decreased breath sounds. 3. Skin breakdown behind the heel. 4. Urine retention.
1. The nurse should assess for signs of skin pressure in the groin area because the Thomas splint, which is a half-ring that slips over the thigh and suspends the lower extremity in direct skeletal traction, may cause discomfort, pressure, or skin irritation in the groin. The nurse always assesses respirations as part of routine vital signs, but assessing for evidence of decreased breath sounds is not a routine assessment related directly to the Thomas splint. The head of the bed can be elevated to facilitate breathing, but not more than 25 degrees, to avoid continually moving the client toward the foot of the bed from the weight of the traction. The nurse always assesses for pressure areas on dependent parts, but assessing for skin breakdown behind the heel is not a routine assessment related directly to the Thomas splint, in which the heel is free of any contact with padding or metal parts of the Pearson attachment for the balanced suspension traction. The client who is in a Thomas splint is able to use a bedpan to urinate, especially the fracture bedpan for a female client and the urinal for a male. Urine retention should not be a special assessment directly related to the Thomas splint, but it may be a client-specific assessment.
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment? 1. Presence of a distal pulse. 2. Pain with a pain rating scale. 3. Vital sign changes. 4. Potential for drug tolerance.
1. The nurse should assess the client's ability to move her toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the first sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's complaints suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out.
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first: 1. Review the results of culture and sensitivity testing of the wound. 2. Look for the presence of a pressure dressing over the wound. 3. Determine if the client has increased pain from exposed nerve endings. 4. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
1. The wound was left open with a three-way drainage system in place to irrigate the debrided wound with normal saline or an antibiotic. Before the debridement, a sample of the wound would be taken for culture and sensitivity testing so that an organism-specific antibiotic could be administered to prevent possible serious sequelae of osteomyelitis. Therefore, the nurse should review the results of the culture and sensitivity report. A pressure dressing would not be applied to an open wound. Rather, a wet-to-dry dressing most likely would be used. There should not be increased pain related to the exposure of nerve endings in the subcutaneous tissue of the wound that was left open to the environment. The bleeding of vessels should be controlled as it would have been if the wound had been closed. Therefore, additional vessel bleeding should not be a problem.
A small child is admitted to the facility with a fever. Which statement made by the child's mother indicates understanding of the nurse's teaching? 1. "I will keep the child in light clothing." 2. "I will starve a fever and feed a cold." 3. "I should bring the child back to the emergency department (ED) if his temperature reaches 103° F (39.4° C)." 4. "If acetaminophen doesn't reduce the fever, I can give Motrin in 2 hours."
1. "I will keep the child in light clothing." RATIONALE: Evidence-based practice recommends keeping a child with a fever in cool clothing and a comfortable environment. Therefore, the mother exhibits understanding by saying she will keep the child in light clothing. A child with a fever needs increased fluids and a proper diet. It isn't necessary to take the child with a temperature of 103° F to the ED. The current recommendation is to call the child's physician and then go to the ED if the child has a temperature greater than 105° F (40.5° C). Acetaminophen should be given every 4 hours and ibuprofen every 6 to 8 hours to prevent hepatotoxicity. Giving the child ibuprofen 2 hours after acetaminophen would be too soon according to these guidelines.
A nurse is teaching a parent how to administer antibiotics at home to a toddler with acute otitis media. Which statement by the parent indicates that teaching has been successful? 1. "I'll give the antibiotics for the full 10-day course of treatment." 2. "I'll give the antibiotics until my child's ear pain is gone." 3. "Whenever my child is cranky or pulls on an ear, I'll give a dose of antibiotics." 4. "If the ear pain is gone, there's no need to see the physician for another examination of the ears."
1. "I'll give the antibiotics for the full 10-day course of treatment." RATIONALE: The mother demonstrates understanding of antibiotic therapy by stating she'll give the full 10-day course of treatment. Antibiotics must be given for the full course of therapy, even if the child feels well. Otherwise, the infection won't be eradicated. Antibiotics should be taken at ordered intervals to maintain blood levels and not as needed for pain. A reexamination at the end of the course of antibiotics is necessary to confirm that the infection is resolved.
A mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her? 1. "It's common for a child to exhibit regressive behavior when anxious or stressed." 2. "Your child is probably angry about being hospitalized. This is her way of acting out." 3. "Don't worry. It's common for a 3-year-old child to not be fully toilet-trained." 4. "The nurses probably haven't been answering the call button soon enough. They will try to respond more quickly."
1. "It's common for a child to exhibit regressive behavior when anxious or stressed." RATIONALE: The nurse should tell the mother that young children commonly demonstrate regressive behavior when anxious, under stress, or in a strange environment. Although the child could be deliberately wetting the bed out of anger, her behavior most likely isn't under voluntary control. It's appropriate to expect a 3-year-old child to be toilet-trained, but it isn't appropriate to expect the child to be able to use a call button to summon the nurse.
A boy, age 2, is diagnosed with hemophilia, an X-linked recessive disorder. His parents and newborn sister are healthy. The nurse explains how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of X-linked recessive disorders? 1. "Our newborn daughter may be a carrier of the trait." 2. "If we have more sons, all of them will have hemophilia." 3. "All of our offspring will carry the trait for hemophilia." 4. "Our daughter will develop hemophilia when she gets older."
1. "Our newborn daughter may be a carrier of the trait." RATIONALE: The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia.
Parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse is most appropriate? 1. "Pancreatic enzymes promote absorption of nutrients and fat." 2. "Pancreatic enzymes promote adequate rest." 3. "Pancreatic enzymes prevent intestinal mucus accumulation." 4. "Pancreatic enzymes help prevent meconium ileus."
1. "Pancreatic enzymes promote absorption of nutrients and fat." RATIONALE: Pancreatic enzymes are given to a child with cystic fibrosis to aid fat and protein digestion. They don't promote rest or prevent mucus accumulation or meconium ileus.
A nurse is assessing a 10-year-old girl. The girl's mother informs the nurse that she's concerned about her daughter's breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response? 1. "The changes in your daughter's breasts are the first signs of puberty." 2. "This is abnormal and should be assessed by her physician." 3. "I see nothing wrong with her breasts." 4. "The change is a result of increased adipose tissue. Has your daughter gained weight recently?"
1. "The changes in your daughter's breasts are the first signs of puberty." RATIONALE: Stating that such changes are the first signs of puberty is correct because breast bud development — elevation of the nipple and areola to form a breast bud — is the first sign of sexual maturity in girls. It's a normal finding in a girl this age and doesn't require physician assessment. Telling the mother that nothing is wrong doesn't give the mother concrete information to help alleviate her concern. The change isn't a result of weight gain. Sexual maturation continues with the appearance of pubic hair, axillary hair, and menarche, consecutively.
A child, age 10, is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as ordered. The child's left leg is immobilized in a splint. What is an appropriate expected outcome for this child? 1. "The child will change position with minimal discomfort." 2. "The child will bear weight on the affected limb." 3. "The child will ambulate with crutches." 4. "The child will participate in age-appropriate activities."
1. "The child will change position with minimal discomfort." RATIONALE: To prevent pressure ulcers, the child must turn and change positions periodically. However, during the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. Therefore, the nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate outcome because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities isn't a realistic outcome because an acutely ill child isn't likely to be interested in activities; this outcome would be suitable after the acute disease phase ends.
A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to his mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." How should the nurse respond to the mother's statement? 1. "Your baby's behavior indicates stranger anxiety, which is common at his age." 2. "Children who behave that way are developing shy personalities." 3. "Children at his age begin to fear pain." 4. "Your baby's having a temper tantrum, which is common at his age."
1. "Your baby's behavior indicates stranger anxiety, which is common at his age." RATIONALE: Stranger anxiety, common in infants ages 6 to 8 months, may cause the child to cry, cling to the caregiver, and turn away from strangers. Typically, it occurs when the child starts to differentiate familiar and unfamiliar people. The child's behavior doesn't necessarily indicate shyness. According to Piaget, fear of pain characterizes the operational stage of development in school-age children, not infants. Temper tantrums are typical in toddlers who are trying to assert their independence. During a temper tantrum, children may kick, scream, hold their breath, or throw themselves onto the floor rather than cling to a parent.
A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose? 1. 50 mg 2. 100 mg 3. 110 mg 4. 220 mg
1. 50 mg RATIONALE: The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the nurse would calculate: 5 mg/1 kg × 10 kg = 50 mg per dose.
A 14-year-old adolescent with type 1 diabetes checks his blood glucose level at 9:00 p.m. before going to bed. It has been 4 hours since his dinner and his regular insulin dose. His blood glucose level is 60 mg/dl, and he states that he feels a little shaky. What should the nurse suggest? 1. A bedtime snack of an 8-oz glass of milk and graham crackers with peanut butter 2. Going to sleep to decrease the metabolic demands on the body 3. Taking a dose of glucagon 4. Doing nothing because the glucose level is unreliable because the adolescent measured it himself
1. A bedtime snack of an 8-oz glass of milk and graham crackers with peanut butter RATIONALE: Milk is a readily absorbed form of carbohydrate and will elevate blood glucose level rapidly, thus alleviating hypoglycemia. Crackers and peanut butter contain complex carbohydrates and will maintain blood glucose level. Decreased activity and sleep aren't effective for hypoglycemia. Glucagon should be reserved for more severe signs of hypoglycemia, such as disorientation and unconsciousness. To avoid rapid deterioration, steps should be taken whenever hypoglycemia is suspected, regardless of who performed the measurement.
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit? 1. A sunken fontanel 2. Decreased pulse rate 3. Increased blood pressure 4. Low urine specific gravity
1. A sunken fontanel RATIONALE: In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.
A client, 34 weeks pregnant, arrives at the ER with SEVERE abdominal pain, uterine tenderness and an increased uterine tone. The client denies vaginal bleeding. The external fetal monitor shows fetal distress with severe, variable decels. The client most likely has which of the following?
1. Abruptio placentae a client w/ severe abruptio placentae will often have SEVERE abdominal pain. The uterus will have increased tone w/ little to no return to resting tone btw/ contractions. The fetus will start to show signs of distress, with decels in the HR or even fetal death w/ large placental separation. Placenta previa usually involves PAINLESS vaginal bleeding w/out UCs. A molar preg. generally would be detected before 34 weeks gestation. An ecoptic preg. which usually occurs in the FALLOPIAN TUBES, would rupture well before 34 weeks gestation
A 4-year-old, 40-lb (18.1-kg) child is brought to the pediatrician's office. He has upper respiratory symptoms and has had a fever for 2 days. He's diagnosed with a viral illness, and the mother is instructed to treat him with rest, fluids, and antipyretics. Which medication dosage schedule is the most appropriate? 1. Acetaminophen 225 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 180 mg (10 mg/kg/dose) q6h for temperature higher than 102.5° F (39.2° C) 2. Aspirin 290 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 225 mg q4h 3. Acetaminophen 140 mg (5 to 10 mg/kg/dose) q4h for a temperature lower than 102.5° F 4. Acetaminophen 225 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 90 mg (5 mg/kg/dose) q6h for a temperature higher than 102.5° F
1. Acetaminophen 225 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 180 mg (10 mg/kg/dose) q6h for temperature higher than 102.5° F (39.2° C) RATIONALE: The correct dosage schedule for acetaminophen is 10 to 15 mg/kg/dose every 4 hours, and for ibuprofen it's 10 mg/kg/dose every 6 hours for a temperature higher than 102.5° F. Aspirin shouldn't be given to children because of the association between aspirin use in children with influenza virus or chickenpox and Reye's syndrome (a life-threatening condition characterized by vomiting and lethargy that may progress to delirium and coma). Ibuprofen 5 mg/kg/dose is the correct dosage for a child with a temperature lower than 102.5° F.
47. The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? 1. "Some people have a warning that the seizure is about to start." 2. "Auras occur when you are physically and psychologically exhausted." 3. "You're concerned that you do not have auras before your seizures?" 4. "Auras usually cause you to be sleepy after you have a seizure."
1. An aura is a visual, auditory, or olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure.
After a car accident, a child, age 10, is treated in the emergency department for a fractured clavicle and evaluated for a possible head injury. Alert and oriented, she keeps asking what will happen to her. Which nursing diagnosis is most appropriate? 1. Anxiety related to separation from parents and an unfamiliar environment 2. Hypothermia related to head injury 3. Interrupted family processes related to maturational crisis 4. Risk for infection related to sepsis
1. Anxiety related to separation from parents and an unfamiliar environment RATIONALE: The nature of the accident, the child's pain, and the unfamiliar facility environment support a nursing diagnosis of Anxiety related to separation from parents and an unfamiliar environment. A diagnosis of Hypothermia related to head injury isn't appropriate because the child is alert and oriented, indicating that a head injury, if present, isn't severe and is unlikely to cause hypothermia. Unlike the homecoming of a new baby or riding a bicycle for the first time, a car accident isn't a maturational crisis. Risk for infection related to sepsis isn't a plausible nursing diagnosis at this time.
A 14-year-old male reports having right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. A physical examination reveals rebound tenderness and a positive psoas sign. Based on these findings, what should the nurse suspect? 1. Appendicitis 2. Pancreatitis 3. Cholecystitis 4. Constipation
1. Appendicitis RATIONALE: Right lower quadrant pain, rebound tenderness, nausea, vomiting, a positive psoas sign, and a low-grade fever are findings consistent with acute appendicitis. Pancreatitis, cholecystitis, and constipation may mimic appendicitis; however, the pain of pancreatitis is usually localized in the left upper quadrant. Cholecystitis is associated with right upper quadrant pain. Constipation wouldn't cause a fever.
A nurse is teaching a safety class for parents of preschoolers. Which injuries should the nurse include as common among preschoolers? Select all that apply. 1. Automobile accidents 2. Drowning 3. Pedestrian accidents 4. Fire 5. Sexually transmitted diseases 6. Homicide
1. Automobile accidents 2. Drowning 3. Pedestrian accidents 4. Fire RATIONALE: Preschoolers are most susceptible to accident-related injuries. Preschoolers are naturally curious and can't anticipate the results of their actions, which can result in accidents. Sexually transmitted diseases and homicide aren't special risks for preschoolers.
A nurse is conducting an examination of a 6-month-old baby. During the examination, the nurse should be able to elicit which reflex? 1. Babinski's 2. Startle 3. Moro's 4. Dance
1. Babinski's RATIONALE: The nurse should be able to elicit the Babinski's reflex because it may be present the entire first year of life. The startle reflex actually disappears around 4 months of age; the Moro's reflex, by 3 or 4 months of age; and the dance reflex, after the third or fourth week.
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV. 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3. Adolescents with a normal immune system are not at risk for developing AIDS. 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
1. Birth control pills provide protection against unwanted pregnancy but they do not protect females from getting sexually transmitted diseases. In fact, because of the reduced chance of becoming pregnant, some women may find it easier to become involved with multiple partners, increasing the chance of contracting a sexually transmitted disease. 2. There is no vaccine or cure for the HIV virus. 3. Adolescents are among the fastest-growing population to be newly diagnosed with HIV and AIDS. *4. Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.
A nurse is caring for a 17-year-old girl with cystic fibrosis who has been admitted to the hospital to receive antibiotics and respiratory treatment for exacerbation of a lung infection. The girl has a number of questions about her future and the consequences of the disease. Which statements about the course of cystic fibrosis are true? Select all that apply. 1. Breast development is delayed. 2. The client is at risk for developing diabetes. 3. Pregnancy and child-bearing aren't affected. 4. Normal sexual relationships can be expected. 5. Only males carry the gene for the disease. 6. By age 20, the client should be able to decrease the frequency of respiratory treatment.
1. Breast development is delayed. 2. The client is at risk for developing diabetes. 4. Normal sexual relationships can be expected. RATIONALE: Cystic fibrosis delays growth and the onset of puberty. Children with cystic fibrosis tend to be smaller than average size and develop secondary sex characteristics later in life. In addition, clients with cystic fibrosis are at risk for developing diabetes mellitus because the pancreatic duct becomes obstructed as pancreatic tissues are destroyed. Clients with cystic fibrosis can expect to have normal sexual relationships, but fertility becomes difficult because thick secretions obstruct the cervix and block sperm entry. Males and females carry the gene for cystic fibrosis. Pulmonary disease commonly progresses as the client ages, requiring additional respiratory treatment — not less.
A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the child's room, the nurse anticipates using which traction system? 1. Bryant's traction 2. Buck's extension traction 3. Overhead suspension traction 4. 90-90 traction
1. Bryant's traction RATIONALE: Anticipating Bryant's traction is correct because this type of traction is used to treat femoral fractures or congenital hip dislocation in children younger than age 2 who weigh less than 30 lb (13.6 kg). Buck's extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures. Overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is used to treat femoral fractures in children older than age 2.
1. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? a. The client fell out of bed b. The client climbed over the side rails c. The client was found lying on the floor d. The client became restless and tried to get out of bed.
1. C- The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.
A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing? 1. Caring for the same child from admission to discharge 2. Caring for different children each shift to gain nursing experience 3. Taking vital signs for every child hospitalized on the unit 4. Assuming the charge nurse role instead of participating in direct child care
1. Caring for the same child from admission to discharge RATIONALE: Primary care nursing requires that the primary nurse care for the same child (to whom she's assigned) during her scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.
A nurse is taking a history from the parents of a 11-year-old girl admitted with Reye's syndrome. Which illness should the nurse expect the parents to report their child having the previous week? 1. Chickenpox 2. Bacterial meningitis 3. Strep throat 4. Lyme disease
1. Chickenpox RATIONALE: Reye's syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye's syndrome. Bacterial meningitis and strep throat are caused by bacteria and don't lead to Reye's syndrome. Lyme disease is caused by a spirochete and isn't implicated in Reye's syndrome.
An infant boy has just had surgery to repair his cleft lip. Which nursing intervention is important during the immediate postoperative period? 1. Cleaning the suture line carefully with a sterile solution after every feeding 2. Laying the infant on his abdomen to help drain fluids from his mouth 3. Allowing the infant to cry to promote lung reexpansion 4. Giving the baby a pacifier to suck for comfort
1. Cleaning the suture line carefully with a sterile solution after every feeding RATIONALE: To avoid an infection that could adversely affect the cosmetic outcome of the repair, the suture line must be cleaned very gently with a sterile solution after each feeding. Laying an infant on his abdomen after a cleft lip repair isn't appropriate because doing so will put pressure on the suture line, causing damage. The infant can be positioned on his side to drain saliva without affecting the suture line. Crying puts tension on the suture line and should be avoided by anticipating the baby's needs, such as holding and cuddling him. Hard objects such as pacifiers should be kept away from the suture line because they can cause damage.
Proper technique for performing a wound culture includes what? 1. Cleansing the wound prior to obtaining the specimen. 2. Swabbing for the specimen in the area with the largest collection of drainage. 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath. 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen.
1. Cleansing the wound prior to obtaining the specimen; Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride a wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a does will not significantly affect the concentration of wound organisms.
When developing a postoperative care plan for an infant scheduled for cleft lip repair, the nurse should assign highest priority to which intervention? 1. Comforting the child as quickly as possible 2. Maintaining the child in a prone position 3. Restraining the child's arms at all times, using elbow restraints 4. Avoiding disturbing any crusts that form on the suture line
1. Comforting the child as quickly as possible RATIONALE: After surgery to repair a cleft lip, the primary goal of nursing care is to maintain integrity of the operative site. Crying causes tension on the suture line, so comforting the child as quickly as possible is the highest nursing priority. Parents may help by cuddling and comforting the child. The prone position is contraindicated after surgery because rubbing on the sheet may disturb the suture line. Elbow restraints may cause agitation; if used to prevent the child from disturbing the suture line, they must be removed, one at a time, every 2 hours so that the child can exercise and the nurse can assess for skin irritation. Crusts forming on the suture line contribute to scarring and must be cleaned carefully.
A child is to receive valproic acid (Depakote) 10 mg/kg by mouth each day. When teaching the parents about the medication regimen, the nurse should use which approach? 1. Conduct brief teaching sessions, provide written materials during each visit, and repeat information as appropriate. 2. Ask the parents to spend an entire day at the facility so they can learn every detail about their child's care. 3. Call the parents at home and explain everything, allowing time for them to ask questions. 4. Send the parents the drug's package insert so they can become familiar with the medication.
1. Conduct brief teaching sessions, provide written materials during each visit, and repeat information as appropriate. RATIONALE: The nurse should provide simple instructions in short sessions, provide written materials, repeat information, and allow time for questions because these are the most effective teaching methods. Asking the parents to spend the day at the facility, calling the parents at home, and sending the parents the drug's package insert are ineffective teaching strategies because they may be overwhelming for the parents and frustrating for the nurse.
Which sign is likely to indicate abuse in a 4-year-old child? 1. Conflicting stories about the accident or injury from the parents 2. History consistent with the child's injuries 3. Disheveled parental appearance and low socioeconomic status 4. Appropriate emotional response by the caregiver
1. Conflicting stories about the accident or injury from the parents RATIONALE: Conflicting stories about the accident or injury from the parents is a warning sign of abuse. A history consistent with the child's injuries, a disheveled appearance and low socioeconomic status, and an appropriate emotional response by the caregiver aren't indicators of expected or potential abuse.
A nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? 1. Decreased hematuria 2. Increased appetite 3. Increased energy level 4. Decreased diarrhea
1. Decreased hematuria RATIONALE: Decreased hematuria, a sign of improving kidney function, typically is the first sign that a child with APSGN is improving. Increased appetite, an increased energy level, and decreased diarrhea aren't specific to APSGN.
A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse should interpret which finding as a positive response to this drug? 1. Decreased urine output 2. Increased urine glucose level 3. Decreased blood pressure 4. Relief of nausea
1. Decreased urine output RATIONALE: The primary action of DDAVP is to stimulate water reabsorption by the kidneys, thereby decreasing the urine output. DDAVP has no effect on glucose levels, blood pressure, or nausea.
A child, age 4, with a recent history of nausea, vomiting, and diarrhea is admitted to the pediatric unit with a diagnosis of gastroenteritis. During the physical examination, the nurse detects tenting. This finding supports a nursing diagnosis of: 1. Deficient fluid volume related to dehydration. 2. Risk for injury related to capillary fragility. 3. Ineffective peripheral tissue perfusion related to peripheral cyanosis. 4. Activity intolerance related to hypoxia
1. Deficient fluid volume related to dehydration. RATIONALE: Tenting, which indicates decreased skin turgor, is normal only in elderly clients and results from decreased elastin content. However, in other adults and in children, tenting more commonly results from dehydration. This finding supports a nursing diagnosis of Deficient fluid volume related to dehydration. The other diagnoses are inappropriate because capillary fragility, altered tissue perfusion, and hypoxia rarely are associated with gastroenteritis.
A hospitalized infant, age 10 months, begins to choke while eating and quickly becomes unconscious. A foreign object isn't visible in the infant's airway, but respirations are absent and the pulse is 50 beats/minute and thready. The nurse attempts rescue breathing, but the ventilations are unsuccessful. What should the nurse do next? 1. Deliver five back blows. 2. Deliver five chest thrusts. 3. Perform chest compressions. 4. Deliver five abdominal thrusts.
1. Deliver five back blows. RATIONALE: If rescue breathing is unsuccessful in a child younger than age 1, the nurse should deliver five back blows, followed by five chest thrusts, to try to expel the object from the obstructed airway. The nurse shouldn't perform chest compressions because the infant has a pulse and because chest compressions are ineffective without a patent airway for ventilation. The nurse shouldn't use abdominal thrusts for a child younger than age 1 because they can injure the abdominal organs.
A nurse is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature? 1. Eustachian tubes 2. Nasopharynx 3. Tympanic membrane 4. External ear canal
1. Eustachian tubes RATIONALE: The nurse should mention the importance of the eustachian tubes because they're short in a child and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media. The nasopharynx, tympanic membrane, and external ear canal have no unusual features that would predispose a child to otitis media.
A client who is 32 weeks pregnant is being monitored in the antepartum unit for PIH. She suddenly complains of continuous abdominal pain and vaginal bleeding. Which of the following nursing internventions should be included in the care of this client? Check all that apply 1. Evaluate VS 2. Prepare for vaginal delivery 3. Reassure client that she'll be able to continue pregnancy 4. Evaluate FHT 5. Monitor amt of vaginal bleed 6. Monitor I&O
1. Evaluate VS 4. Evaluate FHT 5. Monitor amt of vaginal bleed 6. Monitor I&O The clients Sx indicate that she's experiencing abruptio placenta. The nurse must immed eval the moms well being by eval VS, FWB, by auscultation of heart tones, monitoring amt of blood loss and eval the vol status by measuring I&O. After the severity of the abruption has been determined and blood and fluid have been replaced, prompt C-SECTION delivery of the fetus (not vaginal) is indicated if the fetus is in distress
At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase (Pancrease). At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes? 1. Fatty stools 2. Liquid stools 3. Bloody stools 4. Normal stools
1. Fatty stools RATIONALE: Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes cannot reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. If the parents were administering the pancreatic enzymes correctly, the child would have stools of normal consistency. Noncompliance doesn't cause liquid or bloody stools.
An 8-year-old child has just returned from the operating room after having a tonsillectomy. The nurse is preparing to do a postoperative assessment. The nurse should be alert for which signs and symptoms of bleeding? Select all that apply. 1. Frequent clearing of the throat 2. Breathing through the mouth 3. Frequent swallowing 4. Sleeping for long intervals 5. Pulse rate of 98 beats/minute 6. Bright red vomitus
1. Frequent clearing of the throat 3. Frequent swallowing 6. Bright red vomitus RATIONALE: A classic sign of bleeding after tonsillectomy is frequent swallowing; this sign occurs because blood drips down the back of the throat, tickling it. Other signs include frequent clearing of the throat and vomiting of bright red blood. Vomiting of dark blood may be seen if the child swallowed blood during surgery but doesn't indicate postoperative bleeding. Breathing through the mouth is common because of dried secretions in the nares. Sleeping for long intervals is normal after a client receives sedation and anesthesia. A pulse rate of 98 beats/minute is in the normal range for this age-group.
A nurse-manager in a pediatric intensive care unit notices an increase in nosocomial infections. What should the nurse do next? 1. Gather data on possible reasons for this increase. 2. Report the issue to the Centers for Disease Control and Prevention. 3. Notify infection control that staff members aren't wearing gloves. 4. Talk with the hospital administrator about her concerns.
1. Gather data on possible reasons for this increase. RATIONALE: Gathering data about the reasons for infection or injury is within the scope of nursing practice. It wouldn't be appropriate for the nurse to contact infection control or the Centers for Disease Control and Prevention at this time. After gathering supporting data, the nurse should speak with the hospital administrator about her concerns and findings.
A 29-month-old child who is dehydrated as a result of vomiting requires oral rehydration. Which concept regarding oral rehydration therapy should the nurse consider? 1. Give 1 to 3 teaspoons of fluid every 10 to 15 minutes to set up a baseline for the child's tolerance. 2. Sugar is a good source of nutrition when rehydrating a child. 3. If symptoms persist for more than 72 hours, contact the physician. 4. A child who has three wet diapers each day isn't considered dehydrated.
1. Give 1 to 3 teaspoons of fluid every 10 to 15 minutes to set up a baseline for the child's tolerance. RATIONALE: Giving small amounts of fluid at frequent intervals is the first action a nurse should take when a child is vomiting. Doing so allows the nurse to observe the child's tolerance level. Simple sugars aren't a good source of hydration because of their osmotic affects. The nurse shouldn't wait 72 hours before taking action if a child is vomiting or has diarrhea. Toddlers can become dehydrated in a short time. A physician should see a child whose vomiting or diarrhea persists for 24 to 36 hours. Wet diapers are a good source of determining hydration; however, three wet diapers each day isn't a normal finding for toddler-age children. A hydrated toddler should have six to eight wet diapers per day.
An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the best action for a nurse to take in caring for this dying adolescent? 1. Give him more pain medication to control his pain and suffering. 2. Withhold pain medication because he may become addicted to it. 3. Maintain a strict medication administration schedule. 4. Withhold medication because the adolescent has a low pain threshold.
1. Give him more pain medication to control his pain and suffering. RATIONALE: The adolescent is in severe pain and requires more pain medication. The goal of treatment at this stage of terminal cancer is to make the adolescent as comfortable as possible. Increased tolerance and addiction potential aren't concerns. Strict timing of medication administration doesn't always coincide with an individual's fluctuating pain. The nurse should give the medication even if the adolescent's need for it doesn't match the administration schedule. Pain is what a client says it is; a nurse shouldn't withhold medication or make judgments about a client's pain threshold.
When assessing a child with juvenile hypothyroidism, the nurse expects which finding? 1. Goiter 2. Recent weight loss 3. Insomnia 4. Tachycardia
1. Goiter RATIONALE: Juvenile hypothyroidism results in goiter, weight gain, sleepiness, and a slow heart rate. It doesn't cause weight loss, insomnia, or tachycardia.
38. The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? 1. Ensure that helmets are worn in appropriate areas. 2. Implement daily exercise programs for the staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety glasses.
1. Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs.
Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that: 1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation) 2. It will be acceptable to leave the pad in place for another thirty minutes
1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation); The heating pads need to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat -dry or moist- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.
Twenty-four hours after birth, a neonate hasn't passed meconium. The nurse suspects which condition? 1. Hirschsprung's disease 2. Celiac disease 3. Intussusception 4. Abdominal wall defect
1. Hirschsprung's disease RATIONALE: Failure to pass meconium is an important diagnostic indicator for Hirschsprung's disease. Hirschsprung's disease is a potentially life-threatening congenital large-bowel disorder characterized by the absence or marked reduction of parasympathetic ganglion cells in a segment of the colorectal wall; narrowing impairs intestinal motility and causes severe, intractable constipation leading to partial or complete colonic obstruction. Celiac disease, intussusception, and abdominal wall defects aren't associated with failure to pass meconium.
Which client information collected by the nurse reflects a systemic response to a wound infection? 1. Hyperthermia 2. Exudate 3. Edema 4. Pain
1. Hyperthermia; Hyperthermia is a common systemic response to infection. With hyperthermia, microorganisms or endotoxins stimulate phagocytotic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center, resulting in fever. Exudate, edema, and pain are all signs of infection but are considered local responses to infection or injury.
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? 1. I.V. tubing with a volume-control chamber 2. I.V. tubing with a macrodrip chamber 3. I.V. tubing with a special filter 4. Standard I.V. tubing used for adults
1. I.V. tubing with a volume-control chamber RATIONALE: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber (such as a Buretrol or Solu-set) should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.
In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. 1. Identification of neonates, infants, toddlers, children, and adolescents at all times 2. The facility's physical layout 3. The climate in which the hospital is located 4. Available resources to obtain and maintain the security plan 5. Methods for educating all staff regarding the security plan
1. Identification of neonates, infants, toddlers, children, and adolescents at all times 2. The facility's physical layout 4. Available resources to obtain and maintain the security plan 5. Methods for educating all staff regarding the security plan RATIONALE: When developing a security plan for a pediatric unit, the nurse should consider the identification of neonates, infants, toddlers, children, and adolescents; the facility's physical layout; available resources; and methods for educating staff. She needn't consider the climate in which the hospital is located.
A nurse practicing in a nurse-managed clinic suspects that an 8-year-old child's chronic sinusitis and upper respiratory tract infections may result from allergies. She orders an immunoglobulin assay. Which immunoglobulin would the nurse expect to find elevated? 1. Immunoglobulin E 2. Immunoglobulin D 3. Immunoglobulin G 4. Immunoglobulin M
1. Immunoglobulin E RATIONALE: The nurse would expect elevated immunoglobulin (Ig) E levels because IgE is predominantly found in saliva and tears as well as intestinal and bronchial secretions and, therefore, may be found in allergic disorders. IgD's physiologic function is unknown and constitutes only 1% of the total number of circulating immunoglobulins. IgG is elevated in the presence of viral and bacterial infections. IgM is the first antibody activated after an antigen enters the body, and is especially effective against gram-negative organisms.
When planning care for a child with epiglottiditis, the nurse should assign highest priority to which nursing diagnosis: 1. Ineffective airway clearance 2. Fear 3. Ineffective thermoregulation 4. Risk for disproportionate growth
1. Ineffective airway clearance RATIONALE: Because airway obstruction is a life-threatening complication of epiglottiditis, Ineffective airway clearance takes highest priority. Fear, Ineffective thermoregulation, and Risk for disproportionate growth are important but don't take precedence over Ineffective airway clearance and ensuring airway patency.
Which activity should a nurse recommend to prevent foreign body aspiration in a child during meals? 1. Insist that the child remain seated while eating. 2. Give the child toys to play with while eating. 3. Allow the child to watch television while eating. 4. Allow the child to eat in a separate room.
1. Insist that the child remain seated while eating. RATIONALE: A child should remain seated while eating. The risk of aspiration increases if the child is running, jumping, or talking with food in his mouth. Television and toys are a dangerous distraction to toddlers and young children and should be avoided during meals. A child needs constant supervision and should be monitored while eating snacks and meals.
A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? 1. Instituting droplet precautions 2. Administering acetaminophen (Tylenol) 3. Obtaining history information from the parents 4. Orienting the parents to the pediatric unit
1. Instituting droplet precautions RATIONALE: Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be ordered but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.
A 2-year-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress? 1. Intercostal retractions 2. Bradycardia 3. Decreased level of consciousness (LOC) 4. Flushed skin
1. Intercostal retractions RATIONALE: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis. Bradycardia, LOC, and flushed skin aren't signs of increasing respiratory distress.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? 1. Knee-to-chest 2. Fowler's 3. Trendelenburg's 4. Prone
1. Knee-to-chest RATIONALE: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.
A child, age 8, is immobilized with a hip spica cast. The nurse enters the room and notices the child is withdrawn and avoiding eye contact. The child's mother states, "He's just bored. He's tired of watching television." The nurse should perform which action? 1. Let the child visit the playroom daily. 2. Sit with the child for an hour in the room. 3. Place a telephone in the child's room. 4. Arrange a visit by a cooperative child from the same unit.
1. Let the child visit the playroom daily. RATIONALE: School-age children need peer interaction and thrive on peer approval and acceptance. Allowing the child to visit the playroom daily provides a nonthreatening atmosphere for peer interaction and helps the child feel less isolated. Sitting with the child for an hour wouldn't foster the necessary peer interaction. Placing a telephone in the child's room would allow the child to communicate with family and friends, but could reinforce feelings of isolation. Having another child visit would be appropriate only if the child is of the same age-group.
An adolescent presents with a large round ring with a swollen border on his left arm. He states that he often plays football in a field behind the school. The nurse suspects that he has: 1. Lyme disease. 2. anthrax. 3. impetigo. 4. scarlet fever.
1. Lyme disease. RATIONALE: Lyme disease, which results from a tick bite, is characterized by a large round ring with a raised swollen border at the site of the bite. Treatment at this stage can prevent systemic involvement that could lead to cardiac, neurologic, and musculoskeletal symptoms. Cutaneous anthrax is characterized by a skin lesion that originates as a papule, then develops into a depressed area of black eschar. Impetigo is a clustering of vesicles that ooze and form a crust on the skin. Adolescents rarely develop scarlet fever, which is characterized by rough, red pinpoint lesions concentrated on the trunk and in skin folds.
A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? 1. Measuring the infant's weight 2. Obtaining a stool specimen for analysis 3. Obtaining a urine specimen for analysis 4. Inspecting the infant's posterior fontanel
1. Measuring the infant's weight RATIONALE: Frequent weight measurement provides the most important information about fluid balance and the infant's response to fluid replacement. Although stool or urine analysis may provide some information, the results typically aren't available for at least 24 hours, making the tests less useful than measuring weight. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant.
A 15-month-old toddler has just received his routine immunizations, including diphtheria, tetanus, and acellular pertussis; inactivated polio vaccine; measles, mumps, and rubella; varicella; and pneumococcal conjugate vaccine. What information should the nurse give to the parents before they leave the office? Select all that apply. 1. Minor symptoms can be treated with acetaminophen (Tylenol). 2. Minor symptoms can be treated with aspirin (A.S.A.). 3. Call the office if the toddler develops a temperature above 103° F (39.4° C), seizures, or difficulty breathing. 4. Soreness at the immunization site and mild fever are common. 5. The immunizations prevent the toddler from contracting their associated diseases. 6. The toddler should restrict his activity for the remainder of the day.
1. Minor symptoms can be treated with acetaminophen (Tylenol). 3. Call the office if the toddler develops a temperature above 103° F (39.4° C), seizures, or difficulty breathing. 4. Soreness at the immunization site and mild fever are common. RATIONALE: The nurse should tell the parents that minor symptoms, such as soreness at the immunization site and mild fever, can be treated with acetaminophen or ibuprofen. Aspirin should be avoided in children because of its association with Reye's syndrome. The parents should notify the clinic if serious complications (such as a temperature above 103° F, seizures, or difficulty breathing) occur. Minor discomforts, such as soreness and mild fever, are common after immunizations. Immunizing the child decreases the health risks associated with contracting certain diseases; it doesn't prevent the toddler from acquiring them. Although the child may prefer to rest after immunizations, it isn't necessary to restrict his activity.
A 4-month-old infant has been carried into the emergency department after falling off his parents' bed and hitting his head on the floor. What should the nurse do next? 1. Move the family to an area where an assessment can be completed and call for a physician. 2. Notify the supervisor that an operating room is needed because the physician will want to insert a ventriculoperitoneal (VP) shunt. 3. Assess the infant's vital signs in the triage area and instruct the family to wait until their names are called. 4. Call child protective services because of suspected child endangerment.
1. Move the family to an area where an assessment can be completed and call for a physician. RATIONALE: A head injury in an infant can be extremely serious. The nurse's priority should be to move the infant and family to an area where assessment and treatment can occur. Triaging the infant and having the parents wait for evaluation by a physician is inappropriate because of the potential seriousness of the injury. Although increased intracranial pressure can result from head trauma, it's unlikely that inserting a VP shunt would be the first treatment. The fact that the child was left unattended in an unsafe location is a significant safety issue, but notifying child protective services isn't a priority at this time.
A nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis? 1. Muscular hypotonicity 2. Muscle spasticity 3. Increased mucus viscosity 4. Hypothyroidism
1. Muscular hypotonicity RATIONALE: Several conditions make the child with Down syndrome highly vulnerable to respiratory infections. For example, the hypotonicity of chest muscles in children with Down syndrome leads to diminished respiratory expansion and pooling of secretions, and an underdeveloped nasal bone impairs mucus drainage. Down syndrome isn't associated with muscle spasticity or increased mucus viscosity. Although hypothyroidism is common in children with Down syndrome, it doesn't increase the risk of infection.
When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. What action should the nurse take next? 1. No action is needed; this is a normal finding. 2. Inform the physician of the finding and obtain an order for a chest X-ray. 3. Instruct the parents to bring the infant back in 1 month for reevaluation. 4. Check the infant for signs of respiratory distress.
1. No action is needed; this is a normal finding. RATIONALE: No action is needed by the nurse because in an infant, the anteroposterior diameter is normally twice the lateral diameter (a ratio of 1:2).
A physician orders acetaminophen (Tylenol) elixir, 160 mg every 4 hours, for a 14-month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters? 1. None because this isn't a safe dose 2. 2.5 ml 3. 5 ml 4. 7.5 ml
1. None because this isn't a safe dose RATIONALE: For this client, the safe dose of this drug is 90.8 mg (9.08 kg × 10 mg/kg = 90.8 mg). This dose is equivalent to 2.8 ml. Therefore, the ordered dose isn't safe.
A nurse is caring for a 14-month-old infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent? 1. Obtain consent from the foster parents. 2. Call Child Protective Services. 3. Contact the child's biological mother. 4. Contact the unit's director of nursing.
1. Obtain consent from the foster parents. RATIONALE: Foster parents have the right to consent to medical care of minors in their care. The parents of a minor in foster care don't have authority to make decisions regarding his care. The nurse should call Child Protective Services only if she has concerns about a foster parent's authenticity. The nurse needn't notify the director of nursing unless complications occur.
A mother reports that her school-age child is having some problems in school. Which action would be the priority? 1. Obtain more information from the mother and the child. 2. Refer the child to the school psychologist for testing. 3. Talk to the child's health care provider to understand the child better. 4. Talk to the child's teacher to gain a perspective on the situation.
1. Obtain more information from the mother and the child. RATIONALE: In this situation, the nurse needs more information before proceeding and should question the mother and child about the problems. Referring the child to the school psychologist and talking to the child's health care provider and teacher are all important components of a treatment plan, but obtaining more information comes first.
Which intervention should be included in the care plan for a 6-month-old infant with a nursing diagnosis of Deficient fluid volume related to excessive GI losses in stool and emesis? 1. Oral electrolyte replacement solutions, breast milk, or lactose-free formula 2. I.V. fluid replacement therapy 3. Clear fluids, such as fruit juices, carbonated soft drinks, and gelatin 4. Delayed introduction of food for several days followed by the BRAT (bananas, rice, apples, and toast or tea) diet
1. Oral electrolyte replacement solutions, breast milk, or lactose-free formula RATIONALE: Oral electrolyte replacement solutions, breast milk, or lactose-free formula may be given in small amounts to replace fluid and electrolyte losses in an infant with mild diarrhea and vomiting. I.V. fluids are usually reserved for clients experiencing severe vomiting and dehydration. Fruit juices, carbonated soft drinks, and the BRAT diet, which are high in carbohydrates and low in electrolytes, aren't recommended.
Which finding in a 3-year-old child with acute renal failure requires immediate follow-up? 1. Potassium level of 6.5 mEq/L 2. Blood pressure in right leg of 90/50 mm Hg 3. Abdominal cramps 4. No albumin in the urine
1. Potassium level of 6.5 mEq/L RATIONALE: A potassium level of 6.5 mEq/L requires immediate follow-up because it's considered critically high, making the child prone to cardiac arrhythmias. Whereas a blood pressure of 90/50 mm Hg should be recorded and monitored, it doesn't require immediate follow-up. Abdominal cramping may be caused by several conditions and can be observed over time.
Encouraging fantasy play and participation by children in their own care is a useful developmental approach for which pediatric age-group? 1. Preschool age (3 to 5 years) 2. Adolescence (10 to 19 years) 3. School age (5 to 10 years) 4. Toddler (1 to 3 years)
1. Preschool age (3 to 5 years) RATIONALE: Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible.
After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant? 1. Provide extra oxygen by using a ventilator or through manual bagging. 2. Insert a suction catheter to the appropriate measured length. 3. Insert a few drops of sterile saline solution. 4. Put on clean gloves.
1. Provide extra oxygen by using a ventilator or through manual bagging. RATIONALE: Providing extra oxygen before suctioning is the first step because it helps prevent hypoxemia. Insertion of a suction catheter is performed after preoxygenation. Instilling a few drops of sterile saline solution is no longer part of routine suctioning. ET and tracheal suctioning require sterile technique and sterile gloves, not just clean gloves.
A nurse is interviewing the mother of a 7-year-old child. Which symptom reported by the mother leads the nurse to suspect that the child has type 1 diabetes? 1. Recent bed-wetting 2. Poor appetite 3. Weight gain 4. Boundless energy
1. Recent bed-wetting RATIONALE: Polyuria, recognized by parents as bed-wetting in a child recently toilet-trained, is a hallmark of type 1 diabetes mellitus. Polyphagia is also a hallmark of type 1 diabetes mellitus. A parent is also likely to report weight loss despite excessive eating, not weight gain or a poor appetite. The child with type 1 diabetes mellitus may complain of fatigue rather than boundless energy.
After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action? 1. Removing the restraints every 2 hours 2. Removing the restraints while the infant is asleep 3. Keeping the restraints on both arms only while the child is awake 4. Using the restraints until the infant recovers fully from anesthesia
1. Removing the restraints every 2 hours RATIONALE: Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.
A nurse is caring for an 18-month-old infant 24 hours after surgery to repair a fractured tibia. Which comfort interventions are appropriate? Select all that apply. 1. Reposition the infant as often as needed. 2. Let the infant play with his favorite toy. 3. Allow the infant's family to participate in his care as much possible. 4. Explain to the infant what she's going to do before she does it. 5. Be sure the infant gets at least 14 hours of sleep each night. 6. Give the infant his favorite foods.
1. Reposition the infant as often as needed. 2. Let the infant play with his favorite toy. 3. Allow the infant's family to participate in his care as much possible. 4. Explain to the infant what she's going to do before she does it. RATIONALE: Frequent repositioning helps decrease discomfort and gives the nurse an opportunity to assess for changes in status. Infants and children derive comfort and security from playing with a favorite toy or animal. Such play should be encouraged as long as it's permitted. Familiarity is a positive force with children, and parents should be encouraged to participate in their child's care. The nurse should explain her actions to the infant. Although the infant may not understand each event, it's better for the nurse to provide an explanation rather than leave the infant fearful of what might happen. It isn't necessary for an infant who has undergone surgery to get at least 14 hours of sleep per night. Pain, comfort level, and general anxiety may prevent him from receiving much sleep in the acute-care setting. Giving the infant favorite foods in the first 24 to 48 postoperative hours may not be an option; physicians order postoperative diet regimens.
A nurse should expect a 3-year-old child to be able to perform which action? 1. Ride a tricycle 2. Tie his shoelaces 3. Roller-skate 4. Jump rope
1. Ride a tricycle RATIONALE: The nurse should expect the child to ride a tricycle because, at age 3, gross motor development and refinement in eye-hand coordination enable a child to perform such an action. The fine motor skills required to tie shoelaces and the gross motor skills required for roller-skating and jumping rope develop around age 5.
Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery? 1. Risk for infection 2. Impaired physical mobility 3. Disturbed body image 4. Constipation
1. Risk for infection RATIONALE: Because infection is a serious risk for a client in the early stages of burn recovery, a diagnosis of Risk for infection takes highest priority. Diagnoses of Impaired physical mobility, Disturbed body image, and Constipation may be relevant but take lower priority at this time.
For children from infancy through the preschool years, what is the major stressor posed by hospitalization? 1. Separation from the family 2. Fear of bodily injury 3. Loss of control 4. Fear of pain
1. Separation from the family RATIONALE: For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. To minimize the effects of separation, the nurse may suggest that a family member stay with the child as much as possible. Reducing this stressor may help a young child withstand other possible stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain.
A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess? 1. Severe sore throat, drooling, and inspiratory stridor 2. Low-grade fever, stridor, and a barking cough 3. Pulmonary congestion, a productive cough, and a fever 4. Sore throat, a fever, and general malaise
1. Severe sore throat, drooling, and inspiratory stridor RATIONALE: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
In a family with a 7-year-old child with a chronic illness, which family members feel jealousy, resentment, embarrassment, shame, fear of becoming ill, and guilt at causing the illness? 1. Siblings 2. Parents 3. Child with the illness 4. Grandparents
1. Siblings RATIONALE: When a brother or sister is ill, siblings frequently experience jealousy and resentment of the increased attention given to the ill child, embarrassment and shame, fear of becoming ill, and guilt at causing the illness. Parents may experience grieving, denial, overprotectiveness, rejection, and overcompensation. The ill child may regress to a previous developmental stage and feel anxiety, depression, and anger. Both the child's and the siblings' reactions are influenced by the parents' response. Grandparents may experience ambivalence, disappointment, and grief.
A nurse is assessing an 8-month-old infant during a wellness checkup. Which action is a normal developmental task for an infant this age? 1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon 4. Playing patty-cake
1. Sitting without support RATIONALE: According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. Saying two words is expected of a 15-month-old infant. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infant should be able to play patty-cake.
A child is suspected of having amblyopia ("lazy eye"). To help diagnose this disorder, the child will undergo which test? 1. Snellen's test 2. Near vision test 3. Weber's test 4. Peripheral vision test
1. Snellen's test RATIONALE: To help diagnose amblyopia, the child will undergo the Snellen's test. Snellen's test assesses visual acuity and a child with amblyopia will have decreased visual acuity in the affected eye. The near vision test evaluates near vision. Weber's test is used to determine hearing loss. The peripheral vision test evaluates peripheral vision.
A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? 1. Taking vital signs every 4 hours and obtaining daily weight 2. Obtaining a blood sample for electrolyte analysis every morning 3. Checking every urine specimen for protein and specific gravity 4. Ensuring that the child has accurate intake and output and eats a high-protein diet
1. Taking vital signs every 4 hours and obtaining daily weight RATIONALE: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.
A nurse is caring for a 5-year-old boy with end-stage acquired immunodeficiency syndrome (AIDS). The child confides that he is ready to go to heaven and see his grandpa. The nurse knows that the child's parents aren't comfortable with the idea of discontinuing treatment. What should she do? 1. Talk with the parents about the dying process and make them aware of what their child has confided. 2. Listen to the child but recognize that he's too young to make his own decisions. 3. Tell the child that she will talk with his parents and change their minds. 4. Tell the physician that the family would like to discontinue treatment.
1. Talk with the parents about the dying process and make them aware of what their child has confided. RATIONALE: Chronically ill children commonly recognize their fate, whereas their parents continue to believe they'll become well again. The nurse should talk with the parents about the child's concerns. It's possible that the parents don't know what their child is feeling. Chronically ill children tend to have a good understanding of death, and should have input into decisions about their care. The nurse shouldn't tell the child that she can change the parents' minds; she might not be able to keep that promise. It would be unethical for the nurse to call the physician and misrepresent the parents' wishes.
A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN? 1. The 2-year-old child who has started eating soft, solid foods following a tonsillectomy 2. A 12-month-old infant who has a white blood cell (WBC) count of 34/μl and a fever 3. A 17-month-old infant with a contusion as a result of a motor vehicle accident 4 hours earlier 4. A 22-month-old infant with type 1 diabetes who has a blood glucose level of 277 g/dl
1. The 2-year-old child who has started eating soft, solid foods following a tonsillectomy RATIONALE: The nurse can delegate care of the child who had the tonsillectomy to the LPN because he is stable and likely preparing for discharge to home. The infant with a WBC count of 34/μl and fever requires close monitoring for additional signs of infection. Infection could lead to sepsis or septic shock. Although the infant with contusions from the motor vehicle accident may be stable, children sometimes experience delayed reactions to injury. This infant requires close monitoring for signs or injury or shock. The RN should care for the infant with type 1 diabetes, who could become ill very quickly.
A toddler is being prepared for surgery. Who is responsible for obtaining informed consent? 1. The attending physician 2. The floor nurse 3. The operating room nurse 4. The nursing student
1. The attending physician RATIONALE: The child's physician is legally responsible for obtaining consent and making sure the parents are well informed. This step includes telling the parents why the child needs the procedure, providing accurate information about the procedure, and explaining the risks involved. The floor nurse may serve as a witness to the parent's signature, and is obligated to inform the physician if the parent doesn't seem informed. The operating room nurse must make sure that the informed consent form has been signed; however, it isn't her responsibility to obtain the consent. Nursing students aren't legally allowed to obtain consent, nor should they act as witnesses.
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? 1. The child should stay on penicillin and return for a follow-up appointment. 2. At home, be sure to keep the child on bed rest. 3. All children with rheumatic fever need monthly blood tests. 4. The child should stay out of school until the source of the infection is determined.
1. The child should stay on penicillin and return for a follow-up appointment. RATIONALE: A child with rheumatic fever, which is caused by group A beta-hemolytic streptococci, 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.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure? 1. The foster mother 2. The social worker who placed the infant in the foster home 3. The registered nurse caring for the infant 4. The nurse manager
1. The foster mother RATIONALE: When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social worker, the nurse, and the nurse manager have no legal rights to give consent in this scenario.
A nurse is caring for a 5-year-old child who's in the terminal stages of cancer. Which statements are true? Select all that apply. 1. The parents may be at different stages in dealing with the child's death. 2. The child is thinking about the future and knows he may not be able to participate. 3. The dying child may become clingy and act like a toddler. 4. Whispering in the child's room will help the child to cope. 5. The death of a child may have long-term disruptive effects on the family. 6. The child doesn't fully understand the concept of death.
1. The parents may be at different stages in dealing with the child's death. 3. The dying child may become clingy and act like a toddler. 5. The death of a child may have long-term disruptive effects on the family. 6. The child doesn't fully understand the concept of death. RATIONALE: When dealing with a dying child, parents may be at different stages of grief at different times. The child may regress in his behaviors. The stress of a child's death commonly results in parents' divorce and behavioral problems in siblings. Preschoolers see death as temporary — a type of sleep or separation. They recognize the word "dead" but don't fully understand its meaning. Thinking about the future is typical of an adolescent facing death, not a preschooler. Whispering in front of the child would likely increase his fear of death.
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush. 2. Notify the HCP for an order for an antifungal swish-and-swallow medication. 3. Have the client gargle with an antiseptic-based mouthwash several times a day. 4. Determine what types of food the client has been eating for the last 24 hours.
1. This client probably has oral candidiasis, a fungal infection of the mouth and esophagus. Brushing the teeth and patchy areas will not remove the lesions and will cause considerable pain. *2. This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.* 3. Antiseptic-based mouthwashes usually contain alcohol, which is painful for the client. 4. The foods the client has eaten did not cause this condition. TEST-TAKING HINT: The client is complaining of a "sore mouth." The test taker must notice all the important information in the stem before attempting to choose an answer. How are brushing the area, an antiseptic mouthwash, or the
43. The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any seizures while on this medication."
1. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.
Before performing an otoscopic examination on a child, where should the nurse palpate for tenderness? 1. Tragus, mastoid process, and helix 2. Helix, umbo, and tragus 3. Tragus, cochlea, and lobule 4. Mastoid process, incus, and malleus
1. Tragus, mastoid process, and helix RATIONALE: Before inserting the otoscope, the nurse should palpate the child's external ear, especially the tragus and mastoid process, and should pull the helix backward to determine the presence of pain or tenderness. The umbo, incus, and malleus (parts of the middle ear) and the cochlea (part of the inner ear) aren't palpable.
The nurse cares for a client with a wound in the late regeneration phase of tissue repair. The wound may be protected by applying a: 1. Transparent film 2. Hydrogel dressing 3. Collogenase dressing 4. Wet to dry dressing
1. Transparent film; Wounds in the regeneration phase of healing need to be protected as new tissue grows. Answers 2, 3, and 4 are dressings used to remove nonviable tissue.
a client is being admitted to the antepartum unit for hypovolemia secondary to hyperemesis gravidarum. WHich of the following factors predisposes a client to the development of this? 1. trophoblastic disease 2. maternal age > 35 y.o. 3. malnourished or underweight clients 4. low levels of HCG
1. Trophoblastic disease is associated w/ hyperemesis grav obesity and maternal age younger than 20 y.o. are risk factors too. High levels of estrogen HCG have also been associated with the development.
The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should: 1. allow adequate time for the nursing assistant to complete the task, then follow-up with her. 2. document in the chart that the task has been completed. 3. keep asking the nursing assistant if she has completed the task. 4. assume the nursing assistant has completed the task to her satisfaction.
1. allow adequate time for the nursing assistant to complete the task, then follow-up with her. RATIONALE: The nurse remains accountable for all of the client's care, including tasks that have been delegated to the nursing assistant. The nurse should allow the nursing assistant ample time to complete the task, then follow up with her to make sure she has completed the task. Documentation occurs after the task has been completed satisfactorily. When a task is delegated, it's important to allow team members the authority to complete the assigned task. However, the nurse should follow up with the nursing assistant to make sure she has completed the task satisfactorily; the nurse can't assume that has been done.
A 12-month-old child fell down the stairs. A basilar skull fracture is suspected. The nurse should look for: 1. cerebrospinal fluid otorrhea. 2. deafness. 3. raccoon eyes. 4. Battle sign.
1. cerebrospinal fluid otorrhea. RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull — frontal, ethmoid, sphenoid, temporal, or occipital. Therefore, cerebrospinal fluid otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Battle sign and raccoon eyes occur primarily in orbital, not basilar, fractures.
A physician orders corticosteroids for a child with systemic lupus erythematosus (SLE). The nurse knows that the purpose of corticosteroid therapy for this child is to: 1. combat inflammation. 2. prevent infection. 3. prevent platelet aggregation. 4. promote diuresis.
1. combat inflammation. RATIONALE: Corticosteroids are used to combat inflammation in a child with SLE. To prevent infection, the physician would order antibiotics. Aspirin is used to prevent platelet aggregation. Diuretics, not corticosteroids, promote diuresis.
Parents of a 4-year-old child with acute leukemia ask a nurse to explain the concept of complementary therapy. The nurse should tell the parents that: 1. complementary therapy is an alternative to conventional medical therapies. 2. complementary therapy wouldn't help their child. 3. the physician should talk with them about it. 4. there's no research that indicates that complementary therapies are effective.
1. complementary therapy is an alternative to conventional medical therapies. RATIONALE: The nurse should tell the parents that complementary therapy is a form of alternative medicine. This type of therapy can include diet, exercise, herbal remedies, and prayer. Answering the parents' questions builds rapport and trust. The nurse shouldn't dismiss the parents' idea by telling them complementary therapy wouldn't help their child. The nurse doesn't need to direct the parents to the physician. She can provide the basic information and let the parents determine if they'd like to seek further assistance. Studies indicate that complementary therapies are beneficial to the child and the parents.
A child, age 6, is anxious and upset before a scheduled bone marrow aspiration. During client preparation, the nurse should keep in mind that: 1. describing what the child will hear, see, smell, and feel will help the child cope with the procedure. 2. the child's anxiety will decrease with each successive procedure. 3. no small detail about the procedure should go unexplained. 4. explaining bone marrow function will help the child understand the reason for the procedure.
1. describing what the child will hear, see, smell, and feel will help the child cope with the procedure. RATIONALE: Children cope with situations better when they can anticipate sensations rather than just trying to comprehend technical explanations. Therefore, describing what the child will hear, see, smell, and feel will help the child cope. Commonly, a child's anxiety increases rather than decreases with each successive procedure. A school-age child can't assimilate every detail. A 6-year-old child can't understand an explanation of bone marrow function; also, such an explanation would be irrelevant.
Clients with gestational diabetes are usually managed by which of the following therapies? 1. diet 2. long acting insulin 3. oral hypoglycemic drugs 4. oral hypoglycemic drugs/insulin
1. diet oral hypoglycemics are contraindicated in preg. long acting insulin usually inst needed for blood glucose control in the client with GDM
An adolescent with well-controlled type 1 diabetes has assumed complete management of his disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct him to adjust his therapeutic regimen by: 1. eating a snack before each gymnastics practice. 2. measuring his urine glucose level before each gymnastics practice. 3. measuring his blood glucose level after each gymnastics practice. 4. increasing his morning dosage of intermediate-acting insulin.
1. eating a snack before each gymnastics practice. RATIONALE: Because exercise decreases the blood glucose level, the nurse should instruct him to eat a snack before engaging in physical activity to prevent a hypoglycemic episode. Measuring his urine glucose level before each gymnastics practice is incorrect because the urine glucose level doesn't reflect the current blood glucose level. To prevent hypoglycemia, the blood glucose level should be measured before the activity, not after the activity. Increasing his morning dosage of intermediate-acting insulin may lead to hypoglycemia during gymnastics practice; to avoid this condition, the adolescent may need to decrease, not increase, his morning dosage of intermediate-acting insulin.
A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for: 1. ensuring that the suspected child abuse is reported to local authorities. 2. contacting the infant's next of kin to begin discharge planning. 3. reporting her suspicions to the hospital's chief of pediatric services. 4. contacting the local children's protective service office with an anonymous tip.
1. ensuring that the suspected child abuse is reported to local authorities. RATIONALE: Nurses must report suspicions of child abuse to local authorities. The contact procedure may vary among hospitals, but the nurse is responsible for making the report. Reporting suspected abuse to the hospital's chief of pediatric services isn't appropriate. Contacting the infant's next of kin to begin discharge planning is inappropriate because the infant may not be discharged to his next of kin. Providing an anonymous tip isn't appropriate behavior for a professional nurse. The hospital record is important to the legal process, and the nurse must handle it professionally.
A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers: 1. express negativism. 2. have reliable verbal responses to pain. 3. have a good concept of danger. 4. have little fear.
1. express negativism. RATIONALE: A toddler's increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain — they respond just as strongly to painless procedures as they do to painful ones. Toddlers have little concept of danger and have common fears.
A nurse is caring for a preschooler who sustained deep partial-thickness burns on his hands as a result of touching a hot pot on the stove. When performing discharge teaching, the nurse should: 1. include the child in the teaching process. 2. go into the hallway with the parent to do the teaching. 3. be sure that the child has learned a lesson and won't repeat the action. 4. delay the teaching until both parents are present.
1. include the child in the teaching process. RATIONALE: The nurse should include preschoolers in any discharge teaching she performs. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause and effect. It isn't necessary for both parents to be present during teaching, although it's desirable.
A nurse is caring for a 4-year-old boy who needs a blood transfusion. The physician tells the nurse that the boy's parents must give informed consent. The nurse should: 1. inform the physician that he is legally responsible for obtaining informed consent. 2. recognize that the physician is busy and obtain the consent. 3. perform the procedure without a signed consent form. 4. simply explain the procedure to the child and his parents before performing it.
1. inform the physician that he is legally responsible for obtaining informed consent. RATIONALE: Obtaining informed consent is the physician's responsibility. A nurse should never perform a procedure without informed consent. If a procedure is performed without this signed document, the nurse, physician, and facility could face legal consequences.
A nurse is caring for a child who was involved in a bus accident on his way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that: 1. it's normal for their child to want to sleep with them at night. 2. they should allow their child to eat and sleep when he wants. 3. they should allow their child to watch television programs about the accident. 4. they should immediately seek psychiatric care for their child.
1. it's normal for their child to want to sleep with them at night. RATIONALE: It's normal for children involved in traumatic events to experience regression in growth and development or ability to perform physical tasks. For example, a child who has been in an accident may wish to sleep with his parents. Children recovering from traumatic events should have a routine for school, play, meals, and sleep. The parents shouldn't let the child watch television or other media programs about the accident. Children are very resilient; there's no reason to assume this child needs immediate psychiatric counseling.
Which statement best describes lochia rubra? 1. it contains a mixture of mucus, tissue debris and blood 2. it contains placental fragments, and blood 3. it contains mucus, placental fragments and blood. 4. it contains tissue debris and blood
1. lochia rubra contains a mixture of mucus tissue debris blood normal lochia rubra contains NO PLACENTAL FRAGMENTS
A nurse in the pediatric intensive care unit is caring for the only survivor of a house fire that killed seven people. Reporters from local newspapers and television stations are at the hospital, trying to obtain information about the child's condition. The nurse knows that she: 1. may not disclose information regarding the child's condition. 2. may disclose the child's condition, but not his name. 3. may make a statement about how sad she feels for the little boy's family and friends. 4. should contact an attorney because of the legal issues involved in caring for the child.
1. may not disclose information regarding the child's condition. RATIONALE: According to Health Insurance Portability and Accountability Act standards, a nurse can't provide information regarding a child's care unless the child's parent or guardian authorizes her to do so. It wouldn't be appropriate for the nurse to contact an attorney at this time. Although not legally wrong, it wouldn't be appropriate for the nurse to make a statement about her feelings about the situation.
While examining a 2-year-old child, the nurse sees that the anterior fontanel is open. The nurse should: 1. notify the physician. 2. look for other signs of abuse. 3. recognize this as a normal finding. 4. ask about a family history of Tay-Sachs disease.
1. notify the physician. RATIONALE: Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the physician promptly of this abnormal finding. An open fontanel doesn't indicate abuse and isn't associated with Tay-Sachs disease.
A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should: 1. perform chest physiotherapy every 4 hours. 2. give pancreatic enzymes as ordered. 3. place the child in an oxygen tent and have oxygen administered continuously. 4. serve a high-calorie diet.
1. perform chest physiotherapy every 4 hours. RATIONALE: The nurse should perform chest physiotherapy because it aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients — not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort.
A 1-month-old infant in the neonatal intensive care unit is dying. His parents request that a nurse give the infant an opioid analgesic. The infant's heart rate is 68 beats/minute and his respiratory rate is 18 breaths/minute. He is on room air; oxygen saturation is 92%. The nurse's response to the parents' request should be based on the fact that: 1. providing an analgesic during the last days and hours is an ethically appropriate nursing action. 2. withholding the opioid analgesic during the last days and hours is an ethical duty; administering it would represent assisted suicide. 3. administering an analgesic during the last days and hours is the parents' ethical decision. 4. withholding the opioid analgesic is clinically appropriate because administering it would hasten the infant's death.
1. providing an analgesic during the last days and hours is an ethically appropriate nursing action. RATIONALE: The nurse's action should be based on the fact that all clients, regardless of age, have the right to die with dignity and to be free of pain. Assisted suicide requires some action on the part of the client, which isn't possible in the case a 1-month-old infant. The parent's decision doesn't eliminate the nurse's ethical obligation to the infant and to the nursing profession. Withholding the opioid analgesic isn't appropriate because it isn't known that administering the drug would hasten death in this case.
The parents of a school-age child with a brain tumor have elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is: 1. striving to prevent pain by routine administration of pain medication. 2. administering pain medication promptly when the child requests it. 3. using an age-appropriate tool for effectively assessing pain. 4. alternating stronger opioid pain medications with nonopioid agents.
1. striving to prevent pain by routine administration of pain medication. RATIONALE: When providing comfort measures for a child, the nurse should strive to prevent pain by providing routine pain medication. Although the nurse should administer pain medication promptly, the goal of treatment should be to prevent pain rather than simply respond to it. Assessing pain with an age-appropriate tool is important; however, the effective assessment of pain shouldn't take precedence over the effective treatment of pain. Alternating stronger opioid medications with nonopioid medications may be effective, but the nurse should individualize the treatment to meet the child's needs.
A charge nurse is making evening-shift assignments. A unit nurse has requested that she not be assigned to care for a particular child because she has cared for him for the past four shifts and hasn't been able to leave on time. The charge nurse knows that the child and his family have bonded with the unit nurse. The charge nurse's best action would be to: 1. talk with the unit nurse about the assignment and why she doesn't want to take care of the child tonight. 2. promise the unit nurse that she will help her so she can leave on time. 3. assign the child's care to the unit nurse anyway. 4. acknowledge the unit nurse's request and assign the child's care to another nurse.
1. talk with the unit nurse about the assignment and why she doesn't want to take care of the child tonight. RATIONALE: It's the charge nurse's responsibility to make clinical assignments based on safety and client needs. Talking about her reasons for not wanting to care for the child may enable the unit nurse to recognize her duty to the child and to the unit. Continuity of care is in the child's best interest. A nurse should never promise to perform a duty or action; negative feelings will result if she can't keep her promise. Unless there's a valid reason to assign the child's care to another nurse, the charge nurse should talk with the unit nurse before making the assignment.
Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should: 1. tell the children not to bite their fingernails. 2. not let children share hairbrushes. 3. tell the children to cover their mouths and noses when they cough or sneeze. 4. have their children immunized.
1. tell the children not to bite their fingernails. RATIONALE: Pinworms come out of the intestine through the anus at night to lay eggs, causing perianal itching. The child wakes up and may begin scratching. Eggs under the fingernails are carried to the mouth if the child chews on his nails, and the life cycle of the pinworm continues. In addition to teaching children not to bite their fingernails, parents should keep the nails short and encourage hand washing before food preparation and eating. Sharing hairbrushes contributes to the spread of head lice, not pinworms. Although covering the mouth and nose are hygienic practices to reduce the spread of infections from respiratory droplets, doing so doesn't affect the spread of pinworms. There are no immunizations to protect against pinworms.
A mother of a 4-year-old child asks the nurse how to talk with her daughter about strangers. The little girl is very friendly and her mother is concerned that her child could be abducted. The nurse should tell the mother: 1. to talk with her daughter about what she should do if a stranger talks to her. 2. that she lives in a safe town and shouldn't worry. 3. to talk with her daughter about bad people and remind her to tell Mommy if someone she doesn't know talks to her. 4. contact social services, which is better equipped to respond to her questions.
1. to talk with her daughter about what she should do if a stranger talks to her. RATIONALE: Preschoolers can begin to take a role in their own safety. They must be taught what a stranger is and what to do if a stranger approaches them. Living in a safe town doesn't eliminate the need to warn a child about talking to strangers. Although it's appropriate for the mother to talk with her daughter about strangers and have the daughter tell her if a stranger approaches her, the child needs to be aware of what to do at the time that the situation occurs, not only afterward. Contacting social services isn't appropriate because the nurse is capable of answering the mother's questions.
A 12-year-old child has been receiving aggressive treatment for leukemia for the past year. His prognosis is poor and his parents would like to implement a do-not-resuscitate order. They ask the nurse to discuss their decision with their child because they can't bring themselves to talk with him about it. When approaching this subject with the child, the nurse must first assess: 1. what the child knows about the disease. 2. how the child would like to handle the care plan. 3. what interventions the child would like implemented in the event of cardiac or respiratory arrest. 4. the child's experiences with death.
1. what the child knows about the disease. RATIONALE: When discussing a child's wishes for future care, a nurse must first identify what the child knows about the disease. How severe he perceives the illness to be will significantly affect his thoughts about realistic outcomes. A care plan proposed by a child who doesn't understand his disease process or prognosis won't effectively or realistically reflect his actual health status. A child who doesn't understand his disease process or prognosis might feel frightened or threatened by questions about what interventions he'd like to have implemented in the event of cardiac or respiratory arrest. Although exploring the child's experiences with death would be important, it shouldn't be the initial area of discussion.
A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals: 1. worsening dyspnea. 2. gastric distention. 3. nausea and vomiting. 4. a temperature of 102° F (38.9° C).
1. worsening dyspnea. RATIONALE: Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess.
A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type 1 diabetes and admits the child to the facility for insulin regulation. The physician orders an insulin regimen of insulin (Humulin R) and isophane insulin (Humulin N) administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act? 1. ½ to 1 hour 2. 1 to 2 hours 3. 4 to 8 hours 4. 8 to 10 hours
1. ½ to 1 hour RATIONALE: Regular insulin, a rapid-acting insulin, begins to act in ½ to 1 hour, reaches peak concentration levels in 2 to 10 hours, and has a duration of action of 5 to 15 hours.
After teaching a group of nursing students about the action of sulfonamides, the instructor determines that the teaching was successful when the students state that the action of this class of drugs is primarily which of the following?
1.) Bacteriostatic
The nurse is preparing to administer a prescribed sulfonamide. Which of the following would the nurse do?
1.) Have the client sit up to take the drug 2.) Give the prescribed meds on an empty stomach 3.) Encourage the client to drink additional fluids -Promoting optimal response page 64
When developing the plan of care for a client receiving sulfonamides for treatment of a UTI the nurse identifies actions for encouraging fluid intake and monitoring intake and output based on which nursing diagnosis?
1.) Impaired Urinary elimination
A nurse is preparing a plan of care for an older adult client who is receiving sulfonamide therapy. Which of the following would the nurse include in the plan of care to reduce the likeihood causing renal damage?
1.) Increase fluid intake up to 2000mL if tolerated 2.) Use sulfonamides cautiously in clients with renal impairment -Pg 64: impaired urinary elimination, lifespan considerations
A patient has been prescribed tetracycline drug for rocky mountain spotted fever. the patient also takes antacids. which effects likely to occur?
1.) Increased risk of bleeding
A client is prescribed sulfadiazine one tablet twice daily for 10 days. when reviewing the clients history, the nurse notes that the client is also taking warfarin. the nurse would be alert for which of the following?
1.) Prolonged clotting times
A client is receiving gentamicin assessment of which of the following would lead the nurse to suspect that the client is developing nephrotoxicity?
1.) Proteinuria 2.) Hematuria 3.) Decreased urine output 4.) Increased serum creatinine
After administering sulfonamides to a client, the nurse observes the he has developed a fever, cough and muscular aches. the nurse also observes that he has developed lesions in the form of red wheals on the neck and the mouth. the nurse interprets these findings as indicating which of the following?
1.) Stevens-Johnsons syndrome
A 60 year old client whos on sulfonamide had impaired urinary elimination. she doesn't want to increase her oral fluid intake because of fear of incontinence. which of the following nursing interventions would be most appropriate?
1.) Teach the client the times to take fluids to maintain continence
A patients ordered receive neomycin as a part of the treatment plan for hepatic coma. which should nurse assess before giving
1.) ability to swallow 2.) level of consciousness
a client receiving which of the following would the nurse identify as being increased risk for candida infection?
1.) antibiotics 2.) hypoglycemic agents 3.) immunosuppressive agents 4.) oral contraceptives
the nurse preparing plan of care for client being treated with antiviral drug. which outcome would the nurse most likely identify
1.) client demonstrates an optimal response to therapy 2.)client demonstrates ability to manage adverse reactions 3.) client verbalizes understanding of the therapeutic regimen
the health care professional has recommended sulfonamide therapy for a client while obtaining the clients medical history, the nurse discovers that he is taking oral anticoagulants. which of the following are the possible effects of combining sulfonamide with oral anticoagulants?
1.) increased action of the anticoagulant
A nursing instructor is preparing a teaching plan for a group of nursing students about macrolide antibacterial drugs. which of the following would be expected
1.) macrolides are broad spectrum antibiotics 2.) macrolides are contraindicated clients with renal dysfunction 3.) macrolides may cause visual disturbances 4.)macrolides can be used in clients allergic to penicillin 5.) macrolides can be used to treat a vulgaris (cant see the picture)
A patients been prescribed oral tertracycline for acne. which must nurse include in teaching?
1.) take the drug after food
a nurse suspects that a clients developing salicylism which would help confirm
1.) tinnitus
A client is being discharged with a prescription for sulfasalazine which of the following would the nurse include in the discharge plan?
1.) use protective sunscreen or cover exposed areas when going outside 2.) finish the entire course of sulfonamide even when you feel better E.) Keep follow up appointments
10. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? a. Libel b. Slander c. Assault d. Negligence
10. B- Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (Libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below standard of care for a specific professional group
11. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. What is the most appropriate nursing response? a. "Oh really I will discuss this situation with your son" b. "Let's talk about the ways you can manage your time to prevent this from happening" c. "Do you have any friends that can help you out until you resolve these important issues with your son?" d. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay.
11. D- The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured under a legal obligation. Option 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.
What is the normal amount of weight gain for the second trimester of pregnancy?
12-14 pounds
12. The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to administered. Which action should the nurse take? a. Contact the nursing supervisor b. Administer the dose prescribed c. Hold the medication until the HCP can be contacted d. Administer the recommended dose until the HCP can be located
12. A- If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.
13. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action? a. Call the police b. Cut up the photograph and throw it away c. Call the nursing supervisor and report the incident d. Call the laboratory and ask for the individual's name who sent the photograph
13. C- Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conducts that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.
An infant who weighs 7.5 kg is to receive ampicillin (Omnipen) 25 mg/kg I.V. every 6 hours. How many milligrams should the nurse administer per dose? Record your answer using one decimal place. Answer: milligrams
187.5 milligrams RATIONALE: The nurse should calculate the correct dose using the following equation: 25 mg/kg × 7.5 kg = 187.5 mg
A client has developed oral mucositis as a result of radiation to the head and neck. The nurse shouls teach the client to incorporate which of the following measures in his or her daily home care routine? a) oral hygiene should be performed in the morning and evening b) high-protein foods, such as peanut butter, should be incorporated in the diet c) a glass of wine per day will not pose any further harm to the oral cavity d) a combination of a weak saline and water solution should be used to rinse the mouth before and after each meal
2) D Oral mucositis (irritation, inflammation, and/or ulceration of the mucosa) commonly occurs in clients receiving radiation to the head and neck. Measures need to be taken to soothe the mucosa as well as provide effective cleansing of the oral cavity. A combination of a weak saline and water solution is an effective cleansing agent.
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include? 1. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side. 2. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. 3. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. 4. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches.
2. A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead.
The client with a fractured femur is upset and agitated about her injury and its treatment. She says, "How can I stay like this for weeks? I can't even move!" Which of the following is the most appropriate nursing diagnosis? 1. Impaired physical mobility related to traction. 2. Ineffective coping related to prolonged immobility. 3. Deficient diversional activity related to prolonged hospitalization. 4. Activity intolerance related to impaired mobility.
2. Based on the client's statements, Ineffective coping is the most appropriate nursing diagnosis because the client is voicing frustration about the current situation and her inability to move. The nurse should seek ways to help the client adjust to and cope with her present state of immobility. Emphasis should be placed on what the client can do to care for herself, such as participating in her daily care and exercises to maintain muscle strength, to help her maintain some control over her situation. The data do not support a diagnosis of Impaired mobility, Deficient diversional activities, or Activity intolerance.
The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings? 1. Pulmonary emboli. 2. Osteomyelitis. 3. Fat emboli. 4. Urinary tract infection.
2. Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.
Which of the following interventions would be least appropriate for a client who is in a double hip spica cast? 1. Encouraging the intake of cranberry juice. 2. Advising the client to eat large amounts of cheese. 3. Establishing regular times for elimination. 4. Having the client dangle at the bedside.
2. The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged and the client should be encouraged to drink at least 2,500 mL/ day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following? 1. Use herbal supplements. 2. Eat a diet high in protein and vitamins C and D. 3. Ask the health care provider for a change of antibiotics. 4. Encourage frequent passive range-of-motion to the affected extremity.
2. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.
A nurse is instructing a school-age child with a fracture on proper use of crutches. Which statement made by the nurse is most accurate? 1. "After advancing both crutches the length of one step, move your 'good' leg forward." 2. "After advancing both crutches the length of one step, move your 'bad' leg forward." 3. "Move one crutch forward, then advance your 'good' leg." 4. "Move one crutch forward, then advance your 'bad' leg."
2. "After advancing both crutches the length of one step, move your 'bad' leg forward." RATIONALE: When walking with crutches, a child should be instructed to advance both crutches, then advance the affected leg. The unaffected leg then supports much of the weight associated with ambulation. It wouldn't be effective to move the unaffected leg forward first. It wouldn't be safe for the child to advance only one crutch.
A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer? 1. "If the baby's diaper is dry when she's crying, leave her alone and she'll fall asleep." 2. "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." 3. "Leave your baby alone for 10 minutes. If she hasn't stopped crying by then, pick her up." 4. "Crying at this age indicates hunger. Try feeding her when she cries."
2. "Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs." RATIONALE: The nurse should advise the mother to continue to pick the infant up when she cries because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough for her to associate crying with getting attention, it would be difficult to spoil her at this age. Even if the infant's diaper is dry, a gentle touch may be necessary until she falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry, so the mother shouldn't assume the infant is crying because she's hungry.
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: 1. "Does water ever get into the baby's ears during shampooing?" 2. "Do you give the baby a bottle to take to bed?" 3. "Have you noticed a lot of wax in the baby's ears?" 4. "Can the baby combine two words when speaking?"
2. "Do you give the baby a bottle to take to bed?" RATIONALE: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.
A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents: 1. "Has your child recently been exposed to other children with rheumatic fever?" 2. "Has your child had strep throat recently?" 3. "Does your child have a congenital heart defect?" 4. "Is your child's Haemophilus influenzae vaccine up to date?"
2. "Has your child had strep throat recently?" RATIONALE: Asking if the child had strep throat recently is appropriate because group A streptococcal infection typically precedes rheumatic fever — an inflammatory disease that affects the heart, joints, and central nervous system. Rheumatic fever isn't infectious and can't be transmitted from one person to another. Congenital heart defects don't play a role in the development of rheumatic fever. H. influenzae vaccine doesn't prevent streptococcal infection or rheumatic fever.
A mother of several young children calls the nurse when her school-age child comes down with chickenpox. The nurse provides instruction on communicability and home management of this disease. Which response by the mother indicates effective teaching? 1. "I should keep my child at home until the fever is gone." 2. "I should have my child soak in oatmeal baths twice daily." 3. "I should give my child aspirin every 4 hours until the fever is gone." 4. "I should start checking my other children for lesions in about 4 weeks."
2. "I should have my child soak in oatmeal baths twice daily." RATIONALE: Chickenpox is characterized by pruritic lesions; colloidal oatmeal baths may soothe the skin and relieve itching. Therefore, the mother demonstrates effective teaching by saying she'll soak her child in oatmeal baths. Although a fever is common during the first 24 hours the communicable period extends beyond the febrile stage and a normal temperature shouldn't be used as the basis for letting the child leave home. Chickenpox is communicable from 1 day before the lesions erupt until they dry — approximately 1 week. The child should stay home during this time to prevent disease transmission. Aspirin isn't recommended because it's associated with Reye's syndrome; acetaminophen is a suitable substitute. The incubation period for chickenpox is 2 to 3 weeks; the mother should begin to check the other children for lesions 2 weeks after exposure to the infected child.
A day-shift nurse tells a night-shift nurse that she's been attempting to reduce the risk for Impaired skin integrity related to immobility in a toddler. Which statement by the night-shift nurse should the day-shift nurse question? 1. "I'll gently massage the skin with a lubricating substance." 2. "I'll spread a thin layer of lotion over pressure points." 3. "I'll change the toddler's position frequently." 4. "I'll clean the skin as often as necessary."
2. "I'll spread a thin layer of lotion over pressure points." RATIONALE: Using a lotion on the pressure points will soften the skin and promote its breakdown and therefore, should be avoided. Gently massaging the skin with a lubricating substance is recommended because it will stimulate circulation and help prevent breakdown. Changing the toddler's position frequently will help minimize pressure, prevent edema, and stimulate circulation. Keeping the skin clean will lessen the chances of irritation and breakdown.
A nurse is giving discharge instructions to a parent of a 13-month-old infant who weighs 18 lb (8.2 kg). The nurse knows the parent understands car-seat safety when the parent states: 1. "My infant may ride in a front-facing car seat because he's 1 year old." 2. "My infant may ride in a front-facing car seat as soon as he weighs 21 pounds." 3. "If I have a sports utility vehicle, my infant may ride in a rear-facing or front-facing car seat." 4. "My child will need to ride in a rear-facing care seat until he's 3 years old."
2. "My infant may ride in a front-facing car seat as soon as he weighs 21 pounds." RATIONALE: An infant must be at least 1 year old and weigh at least 20 lb (9.1 kg) to move from a rear-facing car seat to a front-facing car seat. The make or model of the vehicle is irrelevant.
A nurse is caring for a 16-year-old girl who isn't sexually active. The girl asks if she needs a Papanicolaou (Pap) test. The nurse should reply: 1. "Yes, a girl should have a Pap test after she begins to menstruate." 2. "No, it isn't necessary because you aren't sexually active." 3. "Yes, you should have a Pap test because you're 16 years old." 4. "No, it isn't necessary because you aren't yet 21 years old."
2. "No, it isn't necessary because you aren't sexually active." RATIONALE: A 16-year-old girl who isn't sexually active doesn't need a Pap test. When a girl is sexually active or reaches age 18, she should have a Pap test.
A 2-year-old child with a low blood level of the immunosuppressive drug cyclosporine comes to a liver transplant clinic for her appointment. The mother says the child hasn't been vomiting and hasn't had diarrhea, but she admits that her daughter doesn't like taking the liquid medication. Which statement by the nurse is most appropriate? 1. "Let your daughter take her medication only when she wants it; it's okay for her to miss some doses." 2. "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." 3. "Insert a nasogastric (NG) tube and administer the medication using the tube as ordered by the physician." 4. "Give the ordered dose a little bit at a time over 2 hours to ensure administration of the medication."
2. "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." RATIONALE: Because liquid cyclosporine has a very unpleasant taste, diluting it with chocolate milk or orange juice will lessen the strong taste and help the child take the medication as ordered. It isn't acceptable to miss a dose because the drug's effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level. Cyclosporine shouldn't be given by NG tube because it adheres to the plastic tube and, thus, all of the drug may not be administered. Taking the medication over a period of time could negatively affect the blood level.
A mother of a child with sickle cell anemia confides in the nurse that she feels guilty about letting the child run and play with the neighborhood children and that if she had been a better mother, the child wouldn't have suffered a sickle cell crisis. Which response would be most appropriate? 1. "She's just fine now. Don't worry." 2. "Tell me more about how you feel." 3. "But you know that children with sickle cell anemia often have crises." 4. "You shouldn't be so protective of her."
2. "Tell me more about how you feel." RATIONALE: Many parents feel guilty when their child is sick. Therefore, it's most appropriate to encourage parents to talk more about their feelings because doing so provides support and helps to develop a therapeutic relationship. Giving a stereotyped answer, such as "Don't worry," shows a lack of interest in what the parent is feeling. Commenting on the course of the disease doesn't address the parent's feelings. Being judgmental or offering an opinion can also block therapeutic communication by inhibiting the parent from discussing her feelings and developing solutions.
During a well-baby visit, a 2-month-old infant receives diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, pneumococcal vaccine, and Haemophilus influenzae b (Hib) vaccine. The parents ask why the baby must have the Hib vaccine. How should the nurse respond? 1. "This vaccine prevents infection by various strains of the influenza virus." 2. "This vaccine protects against serious bacterial infections, such as meningitis and bacterial pneumonia." 3. "This vaccine prevents infection by the hepatitis B virus." 4. "This vaccine prevents chickenpox."
2. "This vaccine protects against serious bacterial infections, such as meningitis and bacterial pneumonia." RATIONALE: The Hib vaccine provides protection against serious childhood infections caused by H. influenzae type B virus, such as meningitis and bacterial pneumonia. The Hib vaccine doesn't prevent infection by the influenza virus, hepatitis B virus, or the varicella virus (chickenpox). The influenza virus vaccine provides immunity to various strains of the influenza virus. The Heptavax vaccine prevents infection by the hepatitis B virus. The varicella vaccine prevents the chickenpox.
A premature infant has been placed on a home apnea monitor. The nurse is giving discharge instructions to the parents. Which statement should the nurse include in the teaching? 1. "Your baby will probably need to be monitored until at least age 1." 2. "Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." 3. "You can only give your baby sponge baths until monitoring is discontinued because it's dangerous to take the monitor off at any time." 4. "You can expect the monitoring to be discontinued by the time your baby is the equivalent of 34 postgestational weeks of age."
2. "Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required." RATIONALE: Home apnea monitoring helps the physician determine the frequency of apneic events and how long monitoring is required. Use of home monitoring has been helpful in improving neonatal survival. Generally, most infants outgrow apnea of prematurity by the time they're 44 weeks postgestational age. The average length of monitoring is 6 weeks; only occasionally is it required beyond 1 year. The monitor can be removed for bathing and during times when parent or caregiver is physically present and actively engaged with the care of the infant.
A child, age 6, is about to be discharged after treatment for acute rheumatic fever. Which statement by the parents indicates effective discharge teaching? 1. "We will keep our child in bed for at least a week." 2. "We will give our child penicillin every day for 5 years." 3. "We will measure our child's blood pressure every day." 4. "We will keep giving our child corticosteroids."
2. "We will give our child penicillin every day for 5 years." RATIONALE: Parents stating they will give penicillin indicates effective teaching because a child recovering from acute rheumatic fever must receive prophylactic penicillin for at least 5 years. Bed rest isn't indicated once the acute disease phase ends. Rheumatic fever doesn't call for blood pressure monitoring or corticosteroid therapy.
A child has just been admitted to the facility and is displaying fear related to separation from his parents, the room being too dark, being hurt while in the hospital, and having many different staff members come into the room. Based on the nurse's knowledge of growth and development, the child is likely: 1. 7 to 12 months old (an infant). 2. 1 to 3 years old (a toddler). 3. 6 to 12 years old (a school-age child). 4. 12 to 18 years old (an adolescent).
2. 1 to 3 years old (a toddler). RATIONALE: Toddlers show fear of separation from their parents, the dark, loud or sudden noises, injury, strangers, certain persons, certain situations, animals, large objects or machines, and change in environment. Infants show fear of strangers, the sudden appearance of unexpected and looming objects (including people), animals, and heights. School-age children show fear of supernatural beings, injury, storms, the dark, staying alone, separation from parents, things seen on television and in the movies, injury, tests and failure in school, consequences related to unattractive physical appearance, and death. Adolescents show fear of inept social performance, social isolation, sexuality, drugs, war, divorce, crowds, gossip, public speaking, plane and car crashes, and death.
When administering total parenteral nutrition (TPN) through a peripheral I.V. line to a school-age child, what is the lowest amount of glucose that is considered safe and not caustic to small veins that will also provide adequate TPN? 1. 5% glucose 2. 10% glucose 3. 15% glucose 4. 17% glucose
2. 10% glucose RATIONALE: The amount of glucose that is considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. A glucose amount of 5% isn't sufficient nutritional replacement, although it's safe for peripheral veins. Any amount above 10% glucose, such as 15% and 17%, must be administered via central venous access.
An infant, age 6 months, is brought to the clinic for a well-baby visit. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse's knowledge of infant weight gain, which current weight would be within the normal range for this infant? 1. 10.5 lb (4.8 kg) 2. 14 lb (6.4 kg) 3. 17.5 lb (7.9 kg) 4. 21 lb (9.5 kg)
2. 14 lb (6.4 kg) RATIONALE: Birth weight typically doubles by age 6 months and triples by age 12 months. Therefore, an infant who weighed 7 lb (3.2 kg) at birth should weigh 14 lb (6.4 kg) at age 6 months.
A client is 33 weeks pregnant and has had diabetes since she was 21. When checking her fasting blood sugar level, which values indicate the clients disease was controlled. 1. 45 mg/dl 2. 85 mg/dl 3. 120 mg/dl 4. 136 mg/dl
2. 85 mg/dl recommended fasting blood sugar levels in pregnant clients w/ dm are 60-90 mg/dl a fasting blood sugar level of 45mg/dl is low and may result in hypoglyecemia a bs level below 120mg/dl is recommeded for 1hour postprandial values a bs level above 136 mg/dl in a pregnant client indicates hyperglycemia
A charge nurse on the pediatric unit informs the staff nurse that four children require attention. Which child should the nurse see first? 1. An 8-year-old child admitted from the postanesthesia care unit who's complaining of pain 2. A 10-year-old child with asthma whose oxygen saturation levels are dropping 3. A 7-year-old child whose mother is waiting for discharge instructions 4. A 9-year-old child with a broken leg who wants help moving from the bed to the chair
2. A 10-year-old child with asthma whose oxygen saturation levels are dropping RATIONALE: Decreasing oxygen saturation levels indicate difficulty breathing and increased work of breathing. Airway, breathing, and circulation always take priority. The children complaining of pain and waiting for discharge instructions don't take priority because administration of pain medication and reviewing discharge instructions can be delegated to another registered nurse. Moving a client from the bed to the chair can be delegated to a nursing assistant.
A nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements about infant development are true? Select all that apply. 1. A 6-month-old infant has difficulty holding objects. 2. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. 3. A teething ring is appropriate for a 6-month-old infant. 4. Stranger anxiety usually peaks at 12 to 18 months. 5. Head lag is commonly noted in infants at age 6 months. 6. Lack of visual coordination usually resolves by age 6 months.
2. A 6-month-old infant can usually roll from prone to supine and supine to prone positions. 3. A teething ring is appropriate for a 6-month-old infant. 6. Lack of visual coordination usually resolves by age 6 months. RATIONALE: Gross motor skills of the 6-month-old infant include rolling from front to back and back to front. Teething usually begins around age 6 months; therefore, a teething ring is appropriate. Visual coordination is usually resolved by age 6 months. At age 6 months, fine motor skills include purposeful grasps. Stranger anxiety normally peaks at 8 months of age. The 6-month-old infant also should have good head control and no longer display head lag when pulled up to a sitting position.
A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? 1. An infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt at 10 a.m. 2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening 3. An infant with an axillary temperature of 100.4 ° F (38° C) on the third postoperative day 4. An infant whose ventriculoperitoneal shunt must be pumped every 2 hours following shunt revision the previous day. The shunt was last pumped at 6 a.m.
2. A restless infant with a high-pitched cry who was transferred from intensive care unit (ICU) the previous evening RATIONALE: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from ICU the previous night, assessing him for increased ICP should be a nursing priority. The infant with a myelomeningocele who is scheduled for surgical placement of a ventriculoperitoneal shunt is stable, so assessing him isn't the most urgent nursing priority. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Pumping a ventriculoperitoneal shunt is less urgent than evaluating increased ICP.
A nurse is reviewing an adolescent's immunization record. Which immunization is inappropriate for an adolescent as a component of preventative care? 1. A tetanus-diphtheria (Td) vaccine, given 7 years after the most recent childhood diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine 2. A second measles-mumps-rubella (MMR) vaccine 3. A tuberculin skin test every other year 4. The hepatitis B vaccine, if not received earlier
2. A second measles-mumps-rubella (MMR) vaccine RATIONALE: A second MMR vaccine is a recommended immunization for an adolescent. A Td vaccine is given 10 years after the most recent childhood DTaP vaccination (not 7 years after). A hepatitis B vaccine is recommended only if the adolescent hasn't received one earlier. A tuberculin skin test is necessary for adolescents who have been exposed to active tuberculosis, have lived in a homeless shelter, have been incarcerated, have lived in or come from an area with a high prevalence of tuberculosis, or are currently working in a health care setting. It isn't routinely administered every other year.
A 4-year-old child has recently been diagnosed with acute lymphocytic leukemia (ALL). What information about ALL should the nurse provide when educating the client's parents? Select all that apply. 1. Leukemia is a rare form of childhood cancer. 2. ALL affects all blood-forming organs and systems throughout the body. 3. Because of the increased risk of bleeding, the child shouldn't brush his teeth. 4. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. 5. There's a 95% chance of obtaining remission with treatment. 6. The child shouldn't be disciplined during this difficult time.
2. ALL affects all blood-forming organs and systems throughout the body. 4. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. 5. There's a 95% chance of obtaining remission with treatment. RATIONALE: In ALL, abnormal white blood cells (WBCs) proliferate, but they don't mature past the blast phase. These blast cells crowd out the healthy WBCs, red blood cells, and platelets in the bone marrow, leading to bone marrow depression. The blast cells also infiltrate the liver, spleen, kidneys, and lymph tissue. Common adverse effects of chemotherapy and radiation include nausea, vomiting, diarrhea, sleepiness, alopecia, anemia, stomatitis, mucositis, pain, reddened skin, and increased susceptibility to infection. There's a 95% chance of obtaining remission with treatment. Leukemia is the most common form of childhood cancer. The child schould continue to brush his teeth, but he should use a soft toothbrush to minimize trauma. The child still needs appropriate discipline and limits. A lack of consistent parenting may lead to negative behaviors and fear.
A physician diagnoses leukemia in a child, age 4, who complains of being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the physiologic effects of leukemia? 1. Ineffective airway clearance related to fatigue 2. Activity intolerance related to anemia 3. Imbalanced nutrition: More than body requirements related to lack of activity 4. Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells
2. Activity intolerance related to anemia RATIONALE: A nursing diagnosis of Activity intolerance related to anemia reflects the nurse's understanding of leukemia's physiologic effects because a child with leukemia may experience anemia from bone marrow depression, such as from chemotherapy or replacement of normal bone marrow elements by immature white blood cells. Anemia results in fatigue, lack of energy, and activity intolerance. The nurse's findings don't support the other diagnoses of Ineffective airway clearance related to fatigue, Imbalanced nutrition: More than body requirements related to lack of activity, and Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells.
A child, age 8, complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses his pain, the child states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate? 1. Ask the child what makes the pain better. 2. Administer pain medication as ordered. 3. Provide diversional activities to distract him. 4. The nurse doesn't need to do anything for this pain level.
2. Administer pain medication as ordered. RATIONALE: A pain rating of 7 out of 10 indicates significant pain. Therefore, the most appropriate action would be to administer pain medication as ordered. The nurse can ask the child what makes the pain better after medication has been given. Providing diversional activities is appropriate only after administration of pain medication. It isn't appropriate to not treat the child's pain.
An adolescent with type 1 diabetes is experiencing a growth spurt. Which treatment approach would be most effective? 1. Administering insulin once per day 2. Administering multiple doses of insulin 3. Limiting dietary fat intake 4. Substituting an oral antidiabetic agent for insulin
2. Administering multiple doses of insulin RATIONALE: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control his blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin.
A 10-year-old child arrives in the emergency department with suspected inhalation anthrax. Which intervention should the nurse perform first? 1. The nurse and other members of the health care team should put on N-95 respirator masks. 2. After obtaining blood cultures, the nurse should insert an I.V. catheter and begin antibiotic and I.V. therapy as ordered. 3. The nurse should move the client to a negative-pressure isolation room. 4. The nurse should prepare to admit the client to a medical-surgical unit.
2. After obtaining blood cultures, the nurse should insert an I.V. catheter and begin antibiotic and I.V. therapy as ordered. RATIONALE: Immediate antibiotic administration has been found to lower mortality rates from inhalation anthrax. Supportive care is essential to successful treatment, so the nurse should obtain blood cultures and immediately start an I.V. and antibiotic therapy. Inhalation anthrax is caused by inhalation of aerosolized anthrax spores, and isn't transmitted from human-to-human contact. Although standard precautions should be upheld, the health care team doesn't need special protective equipment, such as an N-95 respirator mask, and the client doesn't require special isolation, such as a negative-pressure isolation room. Because the client's condition may deteriorate rapidly as anthrax toxins are released into the systemic circulation, he'll most likely require admission to an intensive care unit (not a medical-surgical unit) for monitoring.
A nurse is reviewing her shift assignment. Which child should she assess first? 1. A 5-month-old infant with I.V. fluids infusing 2. An 11-month-old infant receiving chemotherapy through a central venous catheter 3. An 8-year-old child in traction with a femur fracture 4. A 14-year-old child who is postoperative and has a nasogastric tube and an indwelling urinary catheter
2. An 11-month-old infant receiving chemotherapy through a central venous catheter RATIONALE: The nurse should assess the 11-month-old infant with a central venous catheter first. This child takes priority because he has an invasive line and is receiving chemotherapy, which may cause toxic effects. Next, the nurse should assess the 5-month-old infant with an I.V. infusion and then the 14-year-old postoperative child. Because he's the most stable, the nurse can assess the 8-year-old child in traction last.
A nurse is caring for an adolescent girl who was admitted to the hospital's medical unit after attempting suicide by ingesting acetaminophen (Tylenol). The nurse should incorporate which interventions into the care plan for this girl? Select all that apply. 1. Limit care until the girl initiates a conversation. 2. Ask the girl's parents if they keep firearms in their home. 3. Ask the girl if she's currently having suicidal thoughts. 4. Assist the girl with bathing and grooming as needed. 5. Inspect the girl's mouth after giving oral medications. 6. Assure the girl that anything she says will be held in strict confidence.
2. Ask the girl's parents if they keep firearms in their home. 3. Ask the girl if she's currently having suicidal thoughts. 4. Assist the girl with bathing and grooming as needed. 5. Inspect the girl's mouth after giving oral medications. RATIONALE: Safety is the primary consideration when caring for suicidal clients. Because firearms are the most common method used in suicides, the girl's parents should be encouraged to remove firearms from the home, if applicable. Safety also includes assessing for current suicidal ideation. In many cases, clients who are suicidal are depressed and don't have the energy to care for themselves, so the client may need assistance with bathing and grooming. Because depressed and suicidal clients may hide pills in their cheeks, the nurse should inspect the girl's mouth after giving oral medications. Rather than limit care, the nurse should try to establish a trusting relationship through nursing interventions and therapeutic communication. The girl can't be assured of confidentiality when self-destructive behavior is an issue.
A 6-year-old child is being discharged from the emergency department after being diagnosed with varicella (chickenpox). The nurse knows the parents need more medication teaching when they state they will give the child which over-the-counter medication? 1. Ibuprofen (Motrin) 2. Aspirin 3. Acetaminophen (Tylenol) 4. Naproxen (Aleve)
2. Aspirin RATIONALE: The parents require additional teaching if they state they will give their child aspirin because using aspirin during a viral infection has been linked to Reye's syndrome, a serious illness that can lead to brain damage and death in children. If the child requires medication for fever or discomfort, the nurse should recommend acetaminophen (Tylenol) or ibuprofen (Motrin). Naproxen (Aleve) isn't indicated for the treatment of fever.
When assessing a toddler's growth and development, the nurse understands that a child in this age-group displays behavior that fosters which developmental task? 1. Initiative 2. Autonomy 3. Trust 4. Industry
2. Autonomy RATIONALE: The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task whereas developing trust is the infant's task. Developing industry is the task of the school-age child.
A preschool child presents with a history of vomiting and diarrhea for 2 days. Which assessment finding indicates that the child is in the late stages of shock? 1. Tachycardia 2. Bradycardia 3. Irritability 4. Urine output 1 to 2 ml/kg/hour
2. Bradycardia RATIONALE: Bradycardia is a sign of late shock in a child. Cardiovascular dysfunction and impairment of cellular function lead to lowered perfusion pressures, increased precapillary arteriolar resistance, and venous capacitance. Decreased cardiac output occurs in late shock if the circulating volume isn't replaced. Sympathetic nervous innervation has limited compensation mechanisms if the volume isn't replaced. Tachycardia and irritability occur during the early phase of shock as compensatory mechanisms are implemented to increase cardiac output. Normal pediatric urine output is 1 to 2 ml/kg/hour; volumes less than this would indicate a decrease in renal perfusion and activation of the renin-angiotensin-aldosterone system to decrease water and sodium excretion.
2. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure b. Ask the EMS team to sign the informed consent c. Transport the victim to the operating room for surgery d. Call the police to identify the client and locate the family.
2. C- In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action
A nurse caring for an 8-month-old infant diagnosed with respiratory syncytial virus is unable to read a medication dosage written in the infant's medical record. What is the only ethical and responsible solution for the nurse? 1. Erase the original order and rewrite it more clearly. 2. Call the physician and ask for a verbal order to clarify the dosage. 3. Ask another nurse what she thinks the dosage should be. 4. Ask the mother what dosage the infant takes at home.
2. Call the physician and ask for a verbal order to clarify the dosage. RATIONALE: Clarification of written orders must come from the physician or health care provider who wrote the order. A verbal order should be obtained and then entered into the medical chart on a separate line. Assuming or guessing what the writer intended could lead to a medication error. Medical charts are legal documents; information should never be altered or erased. The nurse shouldn't ask the mother because the mother may not be reliable and the physician may have ordered a different dose during hospitalization.
A client's family asks you to explain some keloid scars that the client developed. The best explanation of the keloid scars would be that keloid scars are: 1. Due to a relatively rare inherited tendency. 2. Caused by an abnormal amount of collagen being laid down in scar formation. 3. Most common in pale-skinned people of Northern European ancestry. 4. Caused by repeated and abrupt early disruption of eschar being formed.
2. Caused by an abnormal amount of collagen being laid down in scar formation; Keloid scars are due to an abnormal amount of collagen being laid down in scar formation in the maturation phase, and they are more apt to occur in a dark-skinned person.
Which parameter is an appropriate indicator of pain relief in an adolescent? 1. Intermittent sleeping 2. Change in behavior 3. No change in behavior 4. No change in vital signs
2. Change in behavior RATIONALE: Positive changes in behavior and vital signs are indicators of an effective response to pain medication. Sleeping isn't a reliable indicator of pain relief because the teen may use sleep as a coping mechanism.
A nurse is caring for a 2-year-old child admitted for long-term treatment of a chronic illness. Which action should the nurse take to promote normal childhood growth and development? 1. Allow the child to sleep for at least 12 hours per night. 2. Consult with a play therapist about activities in which the child can participate. 3. Make sure the child is continuously isolated because of his chronic illness and risk of infection. 4. Maintain a diet high in carbohydrates and low in fats.
2. Consult with a play therapist about activities in which the child can participate. RATIONALE: Play is an important part of a child's growth and development. A nurse should facilitate play even when a child has a chronic illness. Consulting a play therapist is one way of facilitating such play. Although it's important for children to get adequate sleep, it isn't necessary for a toddler to get 12 hours' sleep per night. A child with a chronic illness may need to be temporarily isolated, but he should still have interaction with family members. A diet high in carbohydrates and low in fat isn't indicated for every toddler with a chronic illness.
A home health nurse visits a client who twisted an ankle in the morning. The client has an ice bag on the ankle. Which one of the client's chronic conditions contraindicates the use of ice? 1. Gastritis 2. Diabetes 3. Glaucoma 4. Osteoporosis
2. Diabetes; Diabetes contradicts the use for ice. Clients with neurological or circulatory impairment are at risk for injury with ice use.
A 13-year-old with anorexia nervosa is admitted to the facility for I.V. fluid therapy and nutritional management. She says she's worried that the I.V. fluids will make her gain weight. Which nursing diagnosis is most appropriate? 1. Noncompliance (dietary regimen) 2. Disturbed body image 3. Complicated grieving 4. Grieving
2. Disturbed body image RATIONALE: A client with anorexia nervosa has a body image disturbance and views herself as fat despite physical evidence to the contrary. One goal of nursing care is to help her develop realistic perceptions of her body. Although this adolescent has expressed concern about weight gain from I.V. fluids, no information suggests she'll refuse treatment; therefore, a nursing diagnosis of Noncompliance isn't warranted. Likewise, no evidence supports the nursing diagnoses of Complicated grieving and Grieving.
A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises should the nurse provide to the client and his family? Select all that apply. 1. Avoid foods high in folic acid. 2. Drink plenty of fluids. 3. Use cold packs to relieve joint pain. 4. Report a sore throat to an adult immediately. 5. Restrict activity to quiet board games. 6. Wash hands before meals and after playing.
2. Drink plenty of fluids. 4. Report a sore throat to an adult immediately. 6. Wash hands before meals and after playing. RATIONALE: Fluids should be encouraged to prevent stasis in the bloodstream, which can lead to sickling. Sore throats and other cold symptoms should be promptly reported because they may indicate the presence of an infection, which can precipitate a crisis (red blood cells sickle and obstruct blood flow to tissues). Children with sickle cell anemia should learn appropriate measures to prevent infection, such as proper hand-washing techniques and good nutrition practices. Folic acid intake should be encouraged to help support new cell growth; new cells replace fragile, sickled cells. Warm packs should be applied to provide comfort and relieve pain; cold packs cause vasoconstriction. The child should maintain an active, normal life. When the child experiences a pain crisis, he limits his own activity according to his pain level.
a 21 y.o. client, 6 weeks pregnant, is diagnosed with hyperemesis gravidum. This excessive vomiting during pregnancy will often result in which of the following? 1. bowel perforation 2. electrolyte imbalance 3. miscarriage 4. PIH
2. ELECTROLYTE IMBALANCE Excessive vomiting in clients with hyperemesis grav often causes weight loss / fluid and electrolyte, acid base imbalance. PIH and bowel perforation arent r/t hyper grav the effects of hyper grav on the fetus depend on the severity of the disorder. clients w/ severe hyper grav may have low birth weight infant, but the disorder isnt life threatening to the fetus.
A 21 y.o. has arrives to the ER with c/o cramping abdominal pain and mild vaginal bleeding. Pelvic exam shows a left adnexal mass that's tender when palpated. Culdocentesis shows blood in the culdesac. This client probably has which of the following conditions? 1. Abruptio placentae 2. Ecoptic pregnancy 3. Hydatidiform mole 4. Pelvic Inflammatory Disease
2. Ecoptic pregnancy most ecoptic pregnancies dont appear as obvious life threatening med emergencies. THey must be considered in any sexually active woman of childbearing age who c/o menstrual irregularity, cramping abdominal pain, and mild vaginal bleeding. PID, abruptio placentae and hydatidiform moles wont show blood in the cul de sac
After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate? 1. Removing the Logan bow during feedings 2. Holding the infant semi-upright during feedings 3. Burping the infant less frequently 4. Placing the infant on the abdomen after feedings
2. Holding the infant semi-upright during feedings RATIONALE: Holding the infant semi-upright during feedings is appropriate because it helps prevent aspiration. The Logan bow must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on the abdomen could lead to disruption of the suture line if the infant rubs the face.
When assessing a child for impetigo, the nurse expects which assessment findings? 1. Small, brown, benign lesions 2. Honey-colored, crusted lesions 3. Linear, threadlike burrows 4. Circular lesions that clear centrally
2. Honey-colored, crusted lesions RATIONALE: In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is: 1. Risk for Impaired Skin Integrity 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection
2. Impaired Skin Integrity; The client has an actual impairment of the skin due to the rash and the scratching so is no longer "at risk". Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.
Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.
2. Implement a turning schedule; the client is at increased risk for skin breakdown; A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.
When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse? 1. Attempts by the child to defend or verify what the parent states 2. Incompatibility between the history (mechanism) and the injury 3. Responsibility taken by the child for the act 4. A complaint other than the one associated with the signs of abuse
2. Incompatibility between the history (mechanism) and the injury RATIONALE: The most important criterion on which to base a decision for reporting suspected abuse is an incompatibility between the history and the injury. A maltreated child will rarely betray his parents by saying he has been abused and will, instead, attempt to defend the parent's action and verify the story. The child may even take responsibility for the act in attempt to vindicate them. However, these factors aren't as important as an incompatibility between the history and the injury. A complaint other than the one associated with the signs of abuse (for example, a complaint of being cold when second-degree burns are visible) is a warning sign of abuse but isn't the most important criterion.
A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action best identifies potential complications of this disease? 1. Auscultating breath sounds 2. Instituting cardiac monitoring 3. Monitoring blood pressure 4. Assessing the skin daily
2. Instituting cardiac monitoring RATIONALE: Kawasaki disease sometimes causes cardiac complications, including arrhythmias. Therefore, instituting cardiac monitoring is the best action for detecting such complications. Auscultating for breath sounds, monitoring blood pressure, and assessing the skin daily are also important but not as important as cardiac monitoring.
A child is admitted to the pediatric unit with a serum sodium level of 118 mEq/L. Which nursing action takes highest priority at this time? 1. Replacing fluids slowly as ordered 2. Instituting seizure precautions 3. Administering diuretic therapy as ordered 4. Administering sodium bicarbonate as ordered
2. Instituting seizure precautions RATIONALE: A serum sodium level of 118 mEq/L indicates severe hyponatremia, which places the client at risk for seizures. Therefore, instituting seizure precautions takes highest priority. Fluid and sodium replacement should be done rapidly. Diuretic therapy isn't indicated because it may cause additional sodium loss. In a child with hyperkalemia, administering sodium bicarbonate would be appropriate because it promotes movement of potassium into the intracellular spaces.
When caring for an adolescent who's at risk for injury related to intracranial pathology, which action would maintain stable intracranial pressure (ICP)? 1. Turning the adolescent's head from side to side frequently 2. Keeping the adolescent's head in midline position while raising the head of the bed 15 to 30 degrees 3. Hyperextending the adolescent's head with a blanket roll 4. Suctioning frequently to maintain a clear airway
2. Keeping the adolescent's head in midline position while raising the head of the bed 15 to 30 degrees RATIONALE: Elevating the head of the bed while keeping the adolescent's head in midline position will facilitate venous drainage and avoid jugular compression. Turning the head, hyperextending the neck, and suctioning will increase ICP.
A nurse is reviewing a teaching plan with parents of an infant undergoing repair for a cleft lip. Which instructions are the most appropriate for the nurse to give? Select all that apply. 1. Offer a pacifier as needed. 2. Lay the infant on his back or side to sleep. 3. Sit the infant up for each feeding. 4. Loosen the arm restraints every 4 hours. 5. Clean the suture line after each feeding by dabbing it with saline solution. 6. Give the infant extra care and support.
2. Lay the infant on his back or side to sleep. 3. Sit the infant up for each feeding. 5. Clean the suture line after each feeding by dabbing it with saline solution. 6. Give the infant extra care and support. RATIONALE: The nurse should instruct the parents to lay the infant on his back or side to sleep to prevent trauma to the surgery site. She should also instruct them to feed the infant in the upright position with a syringe and attached tubing to prevent stress to the suture line from sucking. In addition, to prevent crusts and scarring, the suture line should be cleaned after each feeding by dabbing it with half-strength hydrogen peroxide or saline solution. The parents should give the infant extra care and support because he can't meet emotional needs by sucking. Extra attention may also prevent crying, which stresses the suture line. Offering a pacifier isn't appropriate. Pacifiers shouldn't be used during the healing process because they stress the suture line. Arm restraints keep the infant's hands away from his mouth. They should be loosened every 2 hours, not every 4 hours.
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? 1. Hypoglycemia 2. Metabolic alkalosis 3. Metabolic acidosis 4. Hyperkalemia
2. Metabolic alkalosis RATIONALE: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.
Which of the following is best to monitor a fetus of a client with diabetes in her 3rd trimester 1. US exam weekly 2. NST 2x/week 3. Daily contraction stress test at 32 weeks 4. monitoring fetal activity by client weekly
2. NST 2X/week NST is the preferred antepartum HR screening test for pregnant clients with diabetes. NSTs should be done at least 2x per week staring at 32 weeks gestation, as fetal deaths in clients w/ diabetes have been noted within 1 week of a reactive NST. US should be done ever 4-6 weeks to monitor fetal growth. CST wouldnt be initiated at 32 weeks Maternal fetal activity monitoring should be done daily
A woman with a term, uncomplicated pregnancy comes into L&D in early labor saying that she thinks her water broke. Which action should the nurse take? 1. prep the woman for delivery 2. note color, amt and odor of fluid 3. immed contact doctor 4. collect sample of fluid for microbial analysis
2. Noting color, amount and odor of the fluid as well as the time of the rupture, will help guide the nurse in her next action. There's no need to call the doctor immed or prep the client for delivery if the fluid is clear and delivery isnt imminent. ROM isnt unusual in early stages of labor. Fluid collection for microbe analysis isnt routine and theres no concern for infection/maternal fever.
An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note: 1. symmetrical thigh and gluteal folds. 2. Ortolani's sign. 3. increased hip abduction. 4. femoral lengthening.
2. Ortolani's sign. RATIONALE: In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.
A 4-year-old boy is scheduled for a nephrectomy to remove a Wilms' tumor. Which intervention listed in the care plan should the nurse question? 1. Provide preoperative teaching to the child and his parents. 2. Palpate his abdomen to monitor tumor growth. 3. Assess vital signs and report hypertension. 4. Monitor urine for hematuria.
2. Palpate his abdomen to monitor tumor growth. RATIONALE: The abdomen of a child with Wilms' tumor should never be palpated because it may increase the risk of metastasis. All children and their parents require preoperative teaching when surgery is planned. Assessing vital signs and monitoring urine are appropriate interventions because a child with Wilms' tumor may be hypertensive as a result of excessive renin production and may have hematuria.
A nurse observes a 2½-year-old child playing with another child of the same age in the playroom on the pediatric unit. What type of play should the nurse expect the children to engage in? 1. Associative play 2. Parallel play 3. Cooperative play 4. Therapeutic play
2. Parallel play RATIONALE: Two-year-olds engage in parallel play, in which they play side by side but rarely interact. Associative play is characteristic of preschoolers, in which they are all engaged in a similar activity but there is little organization. School-age children engage in cooperative play, which is organized and goal-directed. Therapeutic play is a technique that can be used to help understand a child's feelings; it consists of energy release, dramatic play, and creative play.
A nurse is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen? 1. Occupational therapist 2. Physical therapist 3. Recreational therapist 4. Nurse
2. Physical therapist RATIONALE: After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability. An occupational therapist, who helps the chronically ill or disabled to perform activities of daily living and adapt to limitations, isn't necessary at this time. A recreational therapist, who uses games and group activities to redirect maladaptive energy into appropriate behavior, also isn't required. The nurse hasn't been trained to design an exercise regimen for a child with congenital clubfoot.
A nurse is teaching accident prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents? 1. The toddler should wear a helmet when roller blading. 2. Place locks on cabinets containing toxic substances. 3. Teach the toddler water safety. 4. Don't allow the toddler to use pillows when sleeping.
2. Place locks on cabinets containing toxic substances. RATIONALE: The nurse should tell parents to place locks on cabinets containing toxic substances because a toddler's curiosity and the ability to climb and open doors and drawers make poisoning a concern in this age-group. Roller blading isn't an appropriate activity for toddlers even if the toddler wears a helmet. Toddlers lack the cognitive development to understand water safety. Pillows shouldn't be placed in the crib of an infant to avoid suffocation; however, toddlers may use them.
Which nursing intervention should be included in the care of an unconscious child with Reye's syndrome? 1. Keep his arms and legs flexed. 2. Place the child on a sheepskin. 3. Avoid using lotions on his skin. 4. Place the child in a supine position.
2. Place the child on a sheepskin. RATIONALE: Placing the child with Reye's syndrome on a sheepskin helps to prevent pressure on prominent areas of the body. Rubbing lotion on the extremities stimulates circulation and helps prevent drying of the skin, and therefore shouldn't be avoided. Keeping extremities flexed can lead to contractures. Placing the child supine is contraindicated because of the risk of aspiration and increasing intracranial pressure. The supine position isn't appropriate because it puts pressure on the sacral and occipital areas.
A nurse is developing a plan to teach a mother how to reduce her infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan? 1. Administer antibiotics whenever the infant has a cold. 2. Place the infant in an upright position when giving a bottle. 3. Avoid getting the infant's ears wet while bathing or swimming. 4. Clean the infant's external ear canal daily.
2. Place the infant in an upright position when giving a bottle. RATIONALE: Feeding an infant a bottle in an upright position reduces the pooling of formula or breast milk in the nasopharynx. Formula, in particular, provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. Administering antibiotics whenever the infant has a cold, avoiding getting the ears wet, and cleaning the external ear canal daily don't reduce the risk of an infant developing otitis media.
An 18-month-old child immobilized with traction to the legs has a nursing diagnosis of Deficient diversional activity related to immobility. Which diversional activity is most appropriate for the nurse to include in the care plan? 1. Playing with Tinker toys 2. Playing with a pounding board 3. Playing with a pull toy 4. Playing board games
2. Playing with a pounding board RATIONALE: Playing with a pounding board is a developmentally appropriate diversional activity for a toddler because it not only promotes physical development but also provides an acceptable energy outlet during immobilization. A child younger than age 3 accidentally may swallow Tinker toys and other toys with small parts. Whereas a pull toy is appropriate for a toddler, it isn't appropriate for one who's immobilized. Playing board games is too advanced for a toddler's developmental stage.
When developing a care plan for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? 1. Infancy 2. Preschool age 3. School age 4. Adolescence
2. Preschool age RATIONALE: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.
For a child with hemophilia, what is the most important nursing goal? 1. Enhancing tissue perfusion 2. Preventing bleeding episodes 3. Promoting tissue oxygenation 4. Controlling pain
2. Preventing bleeding episodes RATIONALE: A child with hemophilia is prone to bleeding episodes stemming from coagulatory problems. Therefore, the primary nursing goal is to prevent bleeding episodes and possible hemorrhage. A secondary effect of preventing bleeding episodes is maintenance of tissue perfusion and oxygenation. Hemophilia rarely causes pain.
What is the most common assessment finding in a child with ulcerative colitis? 1. Intense abdominal cramps 2. Profuse diarrhea 3. Anal fissures 4. Abdominal distention
2. Profuse diarrhea RATIONALE: Ulcerative colitis causes profuse diarrhea. Intense abdominal cramps, anal fissures, and abdominal distention are more common in Crohn's disease.
An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate? 1. Administering digestive enzymes before meals as ordered 2. Providing small, frequent meals 3. Administering antibiotics with meals as ordered 4. Providing high-fiber snacks
2. Providing small, frequent meals RATIONALE: Clients with ulcerative colitis, an inflammatory bowel disorder (IBD), tolerate small, frequent meals better than a few large meals daily. Eating large amounts of food may exacerbate the abdominal distention, cramps, and nausea IBD typically causes. Frequent meals also provide the additional calories needed to restore nutritional balance. This adolescent doesn't lack digestive enzymes and therefore doesn't need enzyme supplementation. Antibiotics are contraindicated because they may interfere with the actions of other ordered drugs and because ulcerative colitis isn't caused by bacteria. High-fiber foods may irritate the bowel further.
A nurse notes that an infant develops arm movement before fine-motor finger skills and interprets this as an example of which pattern of development? 1. Cephalocaudal 2. Proximodistal 3. Differentiation 4. Mass-to-specific
2. Proximodistal RATIONALE: Proximodistal development progresses from the center of the body to the extremities, such as from the arm to the fingers. Cephalocaudal development occurs along the body's long axis; for example, the infant develops control over the head, mouth, and eye movements before the upper body, torso, and legs. Mass-to-specific development, sometimes called differentiation, occurs as the child masters simple operations before complex functions and moves from broad, general patterns of behavior to more refined ones.
A nurse is caring for a 2½-year-old child with tetralogy of Fallot (TOF). Which abnormalities are associated with TOF? 1. Aortic stenosis, atrial septal defect, overriding aorta, and left ventricular hypertrophy 2. Pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy 3. Pulmonic stenosis, patent ductus arteriosus, overriding aorta, and right ventricular hypertrophy 4. Transposition of the great vessels, intraventricular septal defect, right ventricular hypertrophy, and patent ductus arteriosus
2. Pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy RATIONALE: TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. The other combinations of defects aren't characteristic of TOF.
A nurse is conducting an infant nutrition class for parents. Which foods are appropriate to introduce during the first year of life? Select all that apply. 1. Sliced beef 2. Pureed fruits 3. Whole milk 4. Rice cereal 5. Strained vegetables 6. Fruit juice
2. Pureed fruits 4. Rice cereal 5. Strained vegetables RATIONALE: The first food provided to a neonate is breast milk or formula. Between ages 4 and 6 months, rice cereal can be introduced, followed by pureed or strained fruits and vegetables, then strained, chopped or ground meat. Infants shouldn't be given whole milk until they are at least age 1. Fruit drinks provide no nutritional benefit and shouldn't be encouraged.
A nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity is most appropriate for the nurse to schedule in the care plan? 1. Playing ping-pong 2. Reading books 3. Climbing on play equipment in the playroom 4. Ambulating without restrictions
2. Reading books RATIONALE: During the acute phase of rheumatic fever, the child should be placed on bed rest to reduce the workload of the heart and prevent heart failure. Therefore, an appropriate activity for this child would be reading books. Playing ping-pong, climbing on play equipment, and ambulating without restrictions are too strenuous during the acute phase.
A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What should the nurse do first? 1. Refer the parent to a support group such as Parents Anonymous. 2. Report the incident to the proper authorities. 3. Prepare the child for foster care placement. 4. Restrict the parent from the child's room.
2. Report the incident to the proper authorities. RATIONALE: Reporting the incident to the proper authorities should be done first because the nurse is required by law to report all incidents of suspected child abuse. When the appropriate authorities have been notified, the child can be placed under protective custody. Later, the nurse may need to prepare the child for foster care placement and refer the parent to a support group. After reporting suspected abuse, the nurse should allow the parent to visit and help care for the child; during these visits, the nurse should exhibit and reinforce positive parenting behaviors.
Rh isoimmunization in a pregnant client develops during which conditions? 1. Rh positive maternal blood crosses into fetal blood, stimulating fetal antibodies. 2. Rh positive fetal blood crosses into maternal blood, stimulating maternal antibodies. 3. Rh Negative fetal blood crosses into maternal blood, stimulating maternal antibodies. 4. Rh negative maternal blood crosses into fetal blood, stimulating fetal antibodies.
2. Rh positive fetal blood crosses into maternal blood, stimulating maternal antibodies. Rh isoimmunization occurs when Rh positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies w/ Rh positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy fetal blood cells.
A child is admitted with a tentative diagnosis of clinical depression. Which assessment finding is most significant in confirming this diagnosis? 1. Irritability 2. Sadness 3. Weight gain 4. Fatigue
2. Sadness RATIONALE: Clinical depression is diagnosed if the child exhibits a depressed mood (sadness) or loss of interest. Irritability isn't diagnostic for depression. Although a depressed child may gain weight and report fatigue, these findings aren't essential to the diagnosis.
Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad
2. Sitting in Fowler's position; None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position.
A child is sent to the school nurse because, according to his teacher, he's constantly scratching his head. When the nurse assesses his hair and scalp, she finds evidence of lice. What did the nurse see? 1. Flaking of the scalp with pink, irritated skin exposed 2. Small white spots that adhere to the hair shaft, close to the scalp 3. Scaly, circumscribed patches on the scalp, with mild alopecia in these areas 4. Multiple tiny pustules on the scalp with no abnormal findings on the hair shafts
2. Small white spots that adhere to the hair shaft, close to the scalp RATIONALE: The small white spots that adhere to the hair shafts are the eggs, or nits, of lice. These are easy to see and can't be brushed off like dandruff. Flaking of the scalp may indicate dandruff or a dry scalp. Scaly pustules, resulting from the scratching, may accompany a lice infestation, but nits would also be found on the hair shafts.
A nurse is auscultating for heart sounds in a 2-year-old child. She notes a grade 1 heart murmur. Which characteristic best describes a grade 1 heart murmur? 1. Equal in loudness to the heart sounds 2. Softer than the heart sounds 3. Can be heard without a stethoscope 4. Associated with a precordial thrill
2. Softer than the heart sounds RATIONALE: A grade 1 heart murmur is commonly difficult to hear and softer than heart sounds. A grade 2 murmur is usually equal in sound to the heart sounds. A grade 4 murmur is associated with a precordial thrill (a palpable manifestation associated with a loud murmur). A grade 6 murmur can be heard without a stethoscope.
A child is diagnosed with pituitary dwarfism. Which pituitary agent will the physician most likely order to treat this condition? 1. Corticotropin zinc hydroxide (Cortrophin-Zinc) 2. Somatrem (Protropin) 3. Desmopressin acetate (DDAVP) 4. Vasopressin (Pitressin)
2. Somatrem (Protropin) RATIONALE: Somatrem is used to treat linear growth failure stemming from hormonal deficiency. Corticotropin zinc hydroxide is used to treat adrenal insufficiency and a variety of other conditions; desmopressin acetate and vasopressin are used to treat diabetes insipidus.
A nurse is caring for a young child with tetralogy of Fallot (TOF). The child is upset and crying. The nurse observes that he's dyspneic and cyanotic. Which position would help relieve the child's dyspnea and cyanosis? 1. Sitting in bed with the head of the bed at a 45-degree angle 2. Squatting 3. Lying flat in bed 4. Lying on his right side
2. Squatting RATIONALE: Placing the child in a squatting position sequesters a large amount of blood to the legs, reducing venous return. Sitting with the head of the bed at a 45-degree angle, lying flat, and lying on the right side don't reduce venous return; therefore, they won't relieve the child's dyspnea and cyanosis. A child with TOF may also assume a knee-chest position to reduce venous return to the heart.
You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV
2. Stage II; Stage I pressure ulcer involves a nonblanchable erythema of intact skin, while a stage II involves a partial-thickness skin loss involving epidermis, dermis, or both, with the ulcer being superficial and presenting as an abrasion, blister, or shallow crater.
A 17 y.o. primpigravida with severe PIH has been receiving mag sulfate IV for 3 hours. The latest assessment reveals DTR of +1, BP 150/100 mmgHg, pulse 92 bpm, respiratory rate 10bpm and urine output 20ml/hr. Which of the following actions would be most approp? 1. Continue monitoring per standards of care 2. Stop the mag sulfate infusion 3. Increase infusion by 5gtt/min 4. Decrease infusion by 5gtt/min
2. Stop the mag sulfate infusion Mag sulfate should be withheld if the clients resp rate or urine output falls or if reflexes are diminished / absent. The client also shows other signs of impending toxicity such as flushing / feeling warm. Inaction wont resolve the clients suppressed DTRs and low RR / urine output. The client is already showing CNS depression bc of excessive magsulfte so increasing the infusion is wrong. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.
A pediatric nurse is caring for a child suspected of having been sexually abused. Which finding would best support the nurse's suspicions? 1. Poor hygiene 2. Swelling of the genitals 3. Fear of parents 4. Poor eye contact
2. Swelling of the genitals RATIONALE: The most likely finding for suspected sexual abuse would be difficulty walking or sitting; pain, swelling, or itching in the genitals; or bruises, bleeding, or lacerations of the genital area. Poor hygiene is a sign of physical neglect. Poor eye contact and fear of parents are common signs of physical, not sexual, abuse.
Which sign is an early indicator of heart failure in an infant with a congenital heart defect? 1. Tachypnea 2. Tachycardia 3. Poor weight gain 4. Pulmonary edema
2. Tachycardia RATIONALE: The earliest sign of heart failure in infants is tachycardia (sleeping heart rate greater than 160 beats/minute) as a direct result of sympathetic stimulation. Tachypnea (respiratory rate greater than 60 breaths/minute in infants) occurs later in response to decreased lung compliance. Poor weight gain is a result of the increased energy demands to the heart and breathing efforts, not an early sign of heart failure itself. Pulmonary edema occurs as the left ventricle fails and blood volume and pressure increase in the left atrium, pulmonary veins, and lungs; it isn't an early sign of heart failure.
While doing the shift assessment on a 5-year-old boy, a nurse notices several bruises on his back and arms. The bruises are different colors and sizes. When she asks the child how he got them, he states, "I fell off of my bike." What should the nurse do next? 1. Contact the physician and tell him to call the police. 2. Talk with the child's parents when they arrive. 3. Contact Child Protective Services to report the injuries. 4. Continue to ask the child how he received the injuries.
2. Talk with the child's parents when they arrive. RATIONALE: A nurse who suspects child abuse should talk with the parents and get additional details about the injuries and compare their story with that of the child. Telling the physician to call the police or contacting Child Protective Services isn't the best action to take at this time. If further investigation continues to raise questions about abuse, these steps may be appropriate. The nurse needn't continue questioning the child.
A nurse working on the adolescent unit has a strained working relationship with a coworker and finds it difficult to work well with her. What is the best way for her to go about defusing this situation? 1. Ask other nurses assigned to the unit to see what they think might improve the situation. 2. Talk with the other nurse and try to work out differences so they don't affect client care. 3. Complain to the nurse-manager about the coworker's attitude. 4. Avoid the other nurse by working different shifts.
2. Talk with the other nurse and try to work out differences so they don't affect client care. RATIONALE: When personal conflicts arise, it's always best to have the individuals involved try to work them out. If the differences are irreconcilable, other trained professionals may be needed to mediate the situation. Gossiping to other nurses, complaining to the nurse-manager, and avoiding the situation by working different shifts don't help resolve the problem.
A physician needs to obtain written informed consent for a surgical procedure on an adolescent. Which situation allows the physician to obtain written informed consent from the adolescent rather than his parents? 1. The adolescent's 18th birthday is the following week. 2. The adolescent is estranged from his parents and lives independently. 3. The adolescent gives his verbal consent to the procedure. 4. The physician doesn't need to obtain consent because the procedure is a minor one.
2. The adolescent is estranged from his parents and lives independently. RATIONALE: An emancipated minor is a person younger than age 18 who is legally recognized as an adult under certain conditions. These conditions include becoming pregnant, getting married, graduating from high school, and living independently. Otherwise, an adolescent is considered a minor until his 18th birthday. Written consent must always be obtained, even if verbal consent is given. Major surgery, minor surgery, diagnostic tests such as biopsies, and treatments such as blood transfusions are all examples of procedures that require written informed consent.
One day after an appendectomy, a 9-year-old child rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. What should the nurse document on the child's chart? 1. The child is in no apparent distress, and no pain medication is needed at this time. 2. The child rates pain at 4 out of 5. Administered pain medication as ordered. 3. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. 4. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain.
2. The child rates pain at 4 out of 5. Administered pain medication as ordered. RATIONALE: Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperative) may rate pain as more intense than children who use active coping behaviors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain.
What is an indication of proper use of a triangle arm sling? 1. The elbow is kept flexed at 90 degrees or more. 2. The knot is placed on either side of the vertebrae of the neck. 3. The sling extends to just proximal of the hand. 4. The sling is removed q2h to assess for circulation and skin integrity.
2. The knot is placed on either side of the vertebrae of the neck; The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae. The elbow should be flexed slightly less than 80 degrees (not > 90 as in option 1) so the hand is above the elbow to prevent dependent swelling. The sling must extend past the wrist in order to support the hand. Although the sling must be removed to check for circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and impractical.
Where should a nurse instill an ophthalmic ointment in a 6-year-old child? 1. The sclera 2. The lower conjunctival sac 3. The upper conjunctival sac 4. The outer canthus
2. The lower conjunctival sac RATIONALE: Ophthalmic ointment is best instilled in the lower conjunctival sac.
A nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which behavior should be brought to the attention of the nurse-manager? 1. The nurse keeps communication channels open among herself, the family, physicians, and other health care providers. 2. The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions. 3. The nurse works with the family members to find ways to decrease their dependence on health care providers. 4. The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently.
2. The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions. RATIONALE: When a nurse attempts to influence a family's decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse's part, creating a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.
A nurse is caring for a toddler who was diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a course of action for their child. Why is it important to have the nurse involved in an ethical discussion about a planned course of treatment? 1. The nurse is viewed as the authority on ethical issues at the hospital. 2. The nurse can act as a liaison between the child, the child's parents, and the health care team. 3. The nurse can easily make time to discuss issues with the parents. 4. It isn't important to involve the nurse in this type of discussion.
2. The nurse can act as a liaison between the child, the child's parents, and the health care team. RATIONALE: It is important to involve the nurse because she can act as a liaison between all parties. The nurse has the most direct contact with the child and his parents, and she can listen to and communicate their wishes for treatment. She can also aid in interpreting information about the child's condition and course of treatment, helping the parents to make an informed decision. The nurse isn't viewed as the authority on ethical issues at the hospital. In fact, hospitals commonly employ ethicists to help with ethical dilemmas. Time shouldn't be a factor when it comes to helping parents make decisions about their child's care.
42. The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop trying to insert anything in the mouth. 3. Take no action because the UAP is handling the situation. 4. Notify the charge nurse of the situation immediately.
2. The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.
An overweight girl, age 15, has lost 12 lb (5.4 kg) in 8 weeks by dieting. Now, after reaching a weight plateau, she has become discouraged. She and the nurse decide she should keep a food diary. What is the primary purpose of keeping such a diary? 1. To help the girl stay busy and more focused on losing weight 2. To help the girl and the nurse analyze how much food she is eating and to identify the circumstances in which she eats 3. To help the nurse and the girl determine whether the the girl has been cheating on her diet 4. To provide a written record for the nurse
2. To help the girl and the nurse analyze how much food she is eating and to identify the circumstances in which she eats RATIONALE: Keeping a food diary allows this adolescent to use the cognitive level of formal operations to help her identify and evaluate eating behaviors of which she may not be aware. The food diary isn't intended to keep the girl busy and focused on losing weight. She needs to engage in other activities instead of focusing on her diet. Using the food diary to check for cheating represents a punitive approach, which is relatively ineffective. The food diary is primarily for the girl's benefit, although the nurse can use it, too.
A nurse is caring for a 9-year-old child who has a grave prognosis after receiving a closed injury from being struck by a car. Which health team member should approach the family about organ donation? 1. Nurse-manager 2. Transplant coordinator 3. Emergency department nurse 4. Pastoral care staff member
2. Transplant coordinator RATIONALE: The transplant coordinator is the best health team member to approach the family about organ donation. The transplant coordinator is typically available to hospitals that routinely perform organ transplants. When the coordinator isn't available, the attending physician or another physician not directly involved in determining brain death should approach the family. Although the emergency department nurse may have admitted the child, she and the nurse-manager aren't directly involved with the child's care or with the family. Pastoral care staff members provide emotional and religious support and aren't involved with approaching the family about organ donation; they may, however, be present in a supportive capacity if the family wishes.
A mother calls the clinic to report that her preschool-age child has had a fever, has been fussy, and now has a rash that started on the neck and has spread to the rest of the child's body. The child was exposed to chickenpox about 3 weeks ago. Which advice is the most important to give the mother? 1. Bring the child in immediately so the diagnosis can be confirmed. 2. Treat the child's symptoms and use diphenhydramine (Benadryl) for itching. 3. Be sure the child stays quiet, and limit the amount of television viewing. 4. After the fever is gone, the child can return to day care.
2. Treat the child's symptoms and use diphenhydramine (Benadryl) for itching. RATIONALE: The most likely explanation for the child's illness is chickenpox. The nurse should review the treatment for chickenpox, which includes acetaminophen for fever and fussiness, and oatmeal baths and diphenhydramine for itching. Unless the child is severely ill or has complications, the child doesn't need to be seen in the clinic for diagnosis confirmation. Limiting a preschooler's television viewing is appropriate but isn't the most important advice. Typically, children will limit their own activities as needed. The child will need to stay out of day care until the lesions of the rash are crusted over.
A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. 1. Initiative versus guilt. 2. Trust versus mistrust. 3. Industry versus inferiority. 4. Identity versus role confusion. 5. Autonomy versus shame and doubt.
2. Trust versus mistrust. 5. Autonomy versus shame and doubt. 1. Initiative versus guilt. 3. Industry versus inferiority. 4. Identity versus role confusion. RATIONALE: During the first stage of Erikson's five stages of psychosocial development, trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. In the second stage, autonomy versus shame and doubt (ages 1 to 3), the child gains control of body functions and becomes increasingly independent. In the third stage, initiative versus guilt (ages 3 to 6), the child develops a conscience and learns about the world through play. In the fourth stage, industry versus inferiority (ages 6 to 12), the child enjoys working on projects with others, follows rules, and forms social relationships. As body changes begin to take place, the child enters the fifth stage, identity versus role confusion (ages 12 to 19), and becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity.
A preschool-age child is admitted to the facility with nephrotic syndrome. Nursing assessment reveals a blood pressure of 100/60 mm Hg, lethargy, generalized edema, and dark, frothy urine. After prednisone (Deltasone) therapy is initiated, which nursing action takes highest priority? 1. Monitoring the child for hypertension 2. Turning and repositioning the child frequently 3. Providing a high-sodium diet 4. Discussing the adverse effects of steroids with the parents
2. Turning and repositioning the child frequently RATIONALE: The child with nephrotic syndrome is at risk for skin breakdown from generalized edema. Because this syndrome typically impairs independent movement, the nurse's highest priority is to turn and reposition the child frequently to help prevent skin breakdown. Frequent turning also helps prevent respiratory infections, which may arise during the edematous phase of nephrotic syndrome. The syndrome typically causes hypotension, not hypertension, from significant loss of intravascular protein and a subsequent drop in oncotic pressure. Dietary sodium should be restricted because it worsens edema. Although the nurse should discuss the adverse effects of steroids with the parents, this action isn't a priority at this time.
Parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment? 1. Stuttering 2. Using gestures to express desires 3. Babbling continuously 4. Playing alongside rather than interacting with peers
2. Using gestures to express desires RATIONALE: Using gestures instead of verbal communication to express desires — especially in a child older than age 15 months — may indicate a hearing or communication impairment. Stuttering is normal in children ages 2 to 4, especially boys. Continuous babbling is a normal phase of speech development in young children. In fact, its absence, not presence, would be cause for concern. Parallel play — playing alongside peers without interacting — is typical of toddlers. However, in an older child, difficulty interacting with peers or avoiding social situations may indicate a hearing deficit.
A woman who's 36 week preg comes into L&D with mild contractions. Which of the following complications should the nurse watch for when the client informs her that she has placenta previa? 1. sudden ROM 2. Vaginal bleeding 3. emesis 4. fever
2. Vaginal bleeding contractions may disrupt the microvascular network in the placenta of the client with placenta previa and result in bleeding. if the separation of the placenta occurs at the margin of the placenta, the blood will escape vaginally. sudden ROM isnt r/t placenta previa fever would indicate an infections process, and emesis isnt r/t placenta previa
A 2-year-old boy is brought into the clinic with an upper respiratory tract infection. During the assessment, the nurse notes some bruising on the arms, legs, and trunk. Which findings should prompt the nurse to evaluate for suspected child abuse? Select all that apply. 1. A few superficial scrapes on the lower legs 2. Welts or bruises in various stages of healing on the trunk 3. A deep blue-black patch on the buttocks 4. One large bruise on the child's thigh 5. Circular, symmetrical burns on the lower legs 6. A parent who's hypercritical of the child and pushes the frightened child away
2. Welts or bruises in various stages of healing on the trunk 5. Circular, symmetrical burns on the lower legs 6. A parent who's hypercritical of the child and pushes the frightened child away RATIONALE: Injuries at various stages of healing in protected or padded areas can be signs of inflicted trauma, leading the nurse to suspect abuse. Burns that are bilateral as well as symmetrical and regular are typical of child abuse. The shape of the burn may resemble the item used to create it, such as a cigarette. When a child is burned accidentally, the burns form an erratic pattern and are usually irregular or asymmetrical. Pushing the child away and being hypercritical are typical behaviors of abusive parents. Superficial scrapes and bruises on the lower extremities are normal in a healthy, active child. A deep blue-black macular patch on the buttocks is more consistent with a Mongolian spot than a traumatic injury that would suggest abuse.
A client at 33 weeks gestation and leaking amniotic fluid is place on an EFM. The monitor indicates uterine irritability and contractions occuring every 4-6 min. The doctor orders terbutaline. Which of the following teaching statements is approp for this client? 1. This medicine will make you breathe better 2. You may feel fluttering or tight sensation in your chest 3. This will dry your moth and make you thirsty 4. You'll need to replace potassium lost by this drug
2. You may feel fluttering or tight sensation in your chest A fluttering or tight sensation in the chest is a common adverse reaction to terbutaline It relives bronchospasm but the client is getting it to reduce uterine motility. Mouth dryness and thirst occur w/ the inhaled form but are unlikely with subcut form Hypokalemia is a potential adverse reaction following large doses of terbutaline but not at doses of 0.25 mg
A staffing agency is sending a licensed practical nurse (LPN) to cover a shift for a pediatric nurse who called out sick. The unit's nurse-manager isn't familiar with the LPN's clinical background or comfort level with pediatric clients. The nurse-manager should assign the LPN to: 1. an 8-year-old child admitted that morning with suspected Reye's syndrome. 2. a 9-year-old child receiving subcutaneous (subQ) insulin for treatment of diabetes mellitus. 3. a 10-year-old child who had a tonsillectomy that morning. 4. a 9-year-old child with Legg-Calve'-Perthes disease.
2. a 9-year-old child receiving subcutaneous (subQ) insulin for treatment of diabetes mellitus. RATIONALE: The nurse-manager should assign the LPN to the child with diabetes mellitus. Because he's receiving subQ insulin rather than I.V. insulin, his diabetes is likely stable. Reye's syndrome is an acute condition with the potential to progress into respiratory depression, seizures, loss of deep tendon reflexes, or other neurologic deficits. This child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery. Legg-Calve'-Perthes Disease is associated with impaired circulation to the femoral capital epiphysis. This condition requires aggressive monitoring.
The phrase gravida 4, para 2 indicated which of the following prenatal histories? 1. a client has been pregnant 4 times and had 2 miscarriages. 2. a client has been pregnant 4 times and had 2 live born children 3. a client has been pregnant 4 times and had 2 c-sections 4. a client has been pregnant 4 times and 2 spontaneous abortions.
2. a client has been pregnant 4 times and had 2 live born children Gravida refers to the number of times a client has been pregnant. Para refers to the # of viable children born. Therefore, the client who's gravida 4, para2 has been pregnant 4x and had 2 live born children.
A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for: 1. redness at the catheter site. 2. abdominal tenderness. 3. abdominal fullness. 4. headache.
2. abdominal tenderness. RATIONALE: The nurse should stay alert for abdominal tenderness because it's an early sign of peritonitis. Redness at the catheter site indicates a skin infection. Abdominal fullness is expected during dialysate infusion. Headache isn't associated with peritonitis.
For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: 1. an arched, side-lying position, with the neck flexed onto the chest. 2. an arched, side-lying position, avoiding flexion of the neck onto the chest. 3. a mummy restraint. 4. a prone position, with the head over the edge of the bed.
2. an arched, side-lying position, avoiding flexion of the neck onto the chest. RATIONALE: For a lumbar puncture, the nurse should place the infant in an arched, side-lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the infant. A mummy restraint would limit access to the lumbar area because it involves wrapping the child's trunk and extremities snugly in a blanket or towel. A prone position isn't appropriate because it wouldn't cause separation of the vertebral spaces.
When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, offering choices helps the child achieve: 1. trust. 2. autonomy. 3. industry. 4. initiative.
2. autonomy. RATIONALE: According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. Offering the child choices about some aspects of care encourages autonomy. An infant is at the stage of trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt.
Human papillomavirus (HPV) causes anogenital warts. Without proper treatment, anogenital warts increase an adolescent female's risk of: 1. gonorrhea. 2. cervical cancer. 3. chlamydial infections. 4. urinary tract infections (UTIs).
2. cervical cancer. RATIONALE: Anogenital warts associated with HPV increase an adolescent female's risk of cervical cancer. This risk mandates treatment of all external lesions. HPV doesn't increase the risk of gonorrhea, chlamydia, or UTIs.
When developing a care plan for an adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on: 1. becoming industrious. 2. establishing an identity. 3. achieving intimacy. 4. developing initiative.
2. establishing an identity. RATIONALE: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from his family. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler.
A nurse is administering I.V. fluids to an infant. Infants receiving I.V. therapy are particularly vulnerable to: 1. hypotension. 2. fluid overload. 3. cardiac arrhythmias. 4. pulmonary emboli.
2. fluid overload. RATIONALE: Infants, small children, and children with compromised cardiopulmonary status receiving I.V. therapy are particularly vulnerable to fluid overload. To prevent fluid overload, the nurse should use a volume-control set and an infusion pump or syringe and place no more than 2 hours' worth of I.V. fluid in the volume-control set at a time. Hypotension, cardiac arrhythmias, and pulmonary emboli aren't problems associated with I.V. therapy in infants.
An infant, age 10 months, is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant solid foods. To help correct this problem, the nurse should: 1. point out that tongue thrusting is the infant's way of rejecting food. 2. instruct the mother to place the food at the back and toward the side of the infant's mouth. 3. advise the mother to puree foods if the child resists them in solid form. 4. suggest that the mother force-feed the child if necessary.
2. instruct the mother to place the food at the back and toward the side of the infant's mouth. RATIONALE: The nurse should instruct the mother to place the food at the back and toward the side of the infant's mouth because it encourages swallowing. Tongue thrusting is a physiologic response to food placed incorrectly in the mouth. Offering pureed foods wouldn't encourage swallowing, which is a learned behavior. Force-feeding is inappropriate because it may be frustrating for both the mother and child and may cause the child to gag and choke when attempting to reject the undesired food; also, it may lead to a higher-than-normal caloric intake, resulting in obesity.
A nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines are contraindicated in children with: 1. diabetes mellitus. 2. leukemia. 3. asthma. 4. cystic fibrosis.
2. leukemia. RATIONALE: The nurse should tell the mother that live virus vaccines shouldn't be administered to children with leukemia because they cause immunosuppression. Inactivated — rather than live — viruses should be administered. Children with diabetes mellitus, asthma, or cystic fibrosis can receive live virus vaccines because they aren't immunosuppressed.
A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L. The physician orders an I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to: 1. eliminate the cause of diarrhea. 2. meet physiologic needs. 3. avoid hyperglycemia. 4. promote normal stool elimination.
2. meet physiologic needs. RATIONALE: A child with vomiting and diarrhea loses excessive fluids and electrolytes, which must be replaced. Fluid and electrolyte replacement can't eliminate the cause of diarrhea, which may result from various factors. Administration of I.V. fluids that contain glucose (such as dextrose 5% in water) may induce, not prevent, hyperglycemia. Fluid and electrolyte replacement has no effect on stool elimination.
A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: 1. assessing vital signs every 30 minutes. 2. monitoring the blood glucose level closely. 3. elevating the head of the bed 60 degrees. 4. providing a daily bath.
2. monitoring the blood glucose level closely. RATIONALE: Most TPN solutions contain a high glucose content, placing the client at risk for hyperglycemia. Therefore, the most important nursing action is to monitor the child's blood glucose level closely. A child receiving TPN isn't likely to require vital sign assessment every 30 minutes or elevation of the head of the bed. A daily bath isn't a priority.
A nurse is teaching bicycle safety to a child and his parents. What protective device should the nurse tell the parents is most important in preventing or lessening the severity of injury related to bicycle crashes? 1. Helmet 2. Knee pads 3. Elbow pads 4. Reflectors
2. observe for behavioral changes. RATIONALE: A well-fitting helmet is the most important safety feature to stress to children and parents because, according to the American Academy of Pediatrics, wearing a helmet correctly can prevent or lessen the severity of brain injuries resulting from bicycle crashes. Knee pads, elbow pads, and reflectors are also important safety devices but they aren't as important as a helmet.`
When caring for a toddler with epiglottiditis, the nurse should first: 1. examine his throat. 2. place a tracheotomy tray at the bedside. 3. administer I.V. fluids. 4. administer antibiotics.
2. place a tracheotomy tray at the bedside. RATIONALE: Placing a tracheotomy tray at the bedside should take priority because acute epiglottiditis is an emergency situation in which inflammation can cause the airway to swell so that it's unable to rise, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation. The nurse should never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottiditis are present because this maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are the priority. Only after a patent airway is secured can antibiotics be given to treat Haemophilus influenzae, a common cause of acute epiglottiditis.
An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include: 1. slapping, kicking, and punching others. 2. poor hygiene and weight loss. 3. loud crying and screaming. 4. pulling hair and hitting.
2. poor hygiene and weight loss. RATIONALE: Signs of neglect include poor hygiene and weight loss because neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, pulling hair, hitting, and punching are examples of forms of physical abuse, not neglect. Loud crying and screaming are normal findings in a 3-year-old boy.
A child's physician orders a drug for home use. Before the child is discharged, the nurse should: 1. teach the family how to adjust the drug dosage according to the child's needs. 2. provide the family with the drug's name, dosage, route, and frequency of administration. 3. instruct the family to encourage the child to take responsibility for ensuring timely drug administration. 4. tell the family to avoid explaining the purpose of the medication to the child.
2. provide the family with the drug's name, dosage, route, and frequency of administration. RATIONALE: Before the child is discharged, the nurse should provide the family with essential facts: the drug's name, dosage, route, and frequency of administration. Generally the physician, not the family or nurse, adjusts dosages. It's unrealistic and unsafe to expect a child to take responsibility for ensuring timely administration of any drug. A child has a right to know the reasons for taking the drug.
A nurse-manager for a community health organization is planning for the home health needs of an 8-year-old child who requires around-the-clock care by nursing assistants. The nurse-manager knows that when working with a nursing assistant, she must: 1. ensure that the work is divided equitably to prevent staff burnout and rapid turnover. 2. provide written instructions, education, and ongoing supervision. 3. ensure that the nursing assistant is paid fairly and for any additional time worked. 4. in the event of limited staff resources, provide health services to those in greatest need.
2. provide written instructions, education, and ongoing supervision. RATIONALE: When working with a nursing assistant, the nurse-manager must provide written instructions, education, and ongoing supervision. Although the nurse-manager should be concerned with the equitable division of work and proper payment for hours worked, these concerns aren't the highest priorities. The provision of health services to those in greatest need is an important overall goal, but isn't specific to working with a nursing assistant.
To obtain the most accurate measurement of an infant's height (length), the nurse should measure: 1. recumbent height with the infant lying on the side. 2. recumbent height with the infant supine. 3. recumbent height with the infant prone. 4. standing height with the infant held upright.
2. recumbent height with the infant supine. RATIONALE: For the most accurate measurement, the nurse should place the infant in a supine position and then measure recumbent height. Measuring recumbent height with the infant lying on the side would yield an inaccurate result. Measuring recumbent height with the infant prone would yield an inaccurately long result because it includes the length of the foot. Measuring standing height with the infant held upright would also yield an inaccurate result, at least until the child no longer needs assistance to stand up straight.
A client diagnosed with preterm labor at 28 weeks gestation. Later, she comes to the emergency dept saying "I think im in labor" The nurse would expect her physical exam to show which condition? 1. painful contractions with no cervical dilation 2. regular uterine contractions with cervical dilation 3. irregular uterine contractions with no cervical dilation 4. irregular uterine contractions with cervical effacement
2. regular uterine contractions (every 10 min or more) along with cervical dilation change before 36 weeks = PTL no cervical change with UC isnt' PTL
An adolescent presents to a community clinic for treatment of vulvar lesions associated with Type 2 herpes simplex. The nurse should: 1. call the adolescent's parents and ask permission to treat their daughter. 2. show the adolescent to a private examination room. 3. inform the adolescent that she can't guarantee her confidentiality. 4. ask the adolescent if her parents know she's promiscuous.
2. show the adolescent to a private examination room. RATIONALE: The nurse should take the client to an examination room to provide privacy. Federal law states that adolescents may obtain treatment for sexually transmitted diseases without parental notification. This adolescent is guaranteed the same confidentiality as older clients. It isn't appropriate for the nurse to ask the adolescent if her parents know she's promiscuous; doing so could undermine the therapeutic relationship.
A charge nurse observes two nurses using inappropriate technique when starting an I.V. on a child. The charge nurse should first: 1. ignore the situation. 2. talk with the nurses about proper technique and the risk of infection resulting from improper technique. 3. talk with the nurse-manager about her observations. 4. talk with the child's parents about infection control.
2. talk with the nurses about proper technique and the risk of infection resulting from improper technique. RATIONALE: A nurse has the responsibility to do no harm. If a nurse observes other health care professionals implementing inappropriate practices, she should address the problem. The charge nurse's first action should be to counsel the nurses on correct I.V. techniques. She should contact the nurse-manager if the behaviors continue. She should never ignore the situation or talk with the child's parents regarding the incident unless a situation develops that requires the parents to be informed.
A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because: 1. they're difficult for clients with PKU to digest. 2. they contain high levels of phenylalanine. 3. they aren't well tolerated in children with PKU until after age 2. 4. they lack phenylalanine, which stimulates muscle growth.
2. they contain high levels of phenylalanine. RATIONALE: PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive mental retardation. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine.
To calculate drug dosages for a 4-year-old child, the physician might use a formula that involves the child's: 1. weight in pounds and ounces. 2. weight in kilograms. 3. height in inches. 4. height in centimeters.
2. weight in kilograms. RATIONALE: To calculate drug dosages for a child, the physician might use a formula that involves the child's weight in kilograms. A second recommended method involves the child's body surface area. Using weight in pound and ounces or height for dosage calculation isn't recommended.
A child, age 5, with an intelligence quotient (IQ) of 65 is admitted to the facility for evaluation. When planning care, the nurse should keep in mind that this child: 1. is within the lower range of normal intelligence. 2. would have a diagnosis of mild mental retardation. 3. would have a diagnosis of moderate mental retardation. 4. would have a diagnosis of severe mental retardation.
2. would have a diagnosis of mild mental retardation. RATIONALE: The nurse should keep in mind that this child would have a diagnosis of mild mental retardation. According to the American Association on Mental Deficiency, a person with an IQ between 50 and 70 is classified as mildly mentally retarded. An IQ above 70 is considered normal. A person with an IQ between 36 and 50 is classified as moderately retarded. One with an IQ below 36 is severely impaired.
Lantus is a long acting clear insulin that last for __ hours
24
A 4-year-old child is ordered to receive 25 ml/hour of I.V. solution. The nurse is using a pediatric microdrip chamber to administer the medication. For how many drops per minute should the microdrip chamber be set? Record your answer using a whole number. Answer: gtt/minute
25 gtt/minute RATIONALE: When using a pediatric microdrip chamber, the number of milliliters per hour equals the number of drops per minute. If 25 ml/hour is ordered, the I.V. should infuse at 25 gtt/minute.
Which drug would the nurse choose to utilize as an antagonist for magnesium sulfate? 1. Oxytocin 2. Terbutaline 3. Calcium gluconate 4. Narcan
3. Calcium gluconate should be kept at the bedside while a client is recieivng mag sulfate infusion. If magnesium toxicity occurs, calcium gluconate is admined as an antidote oxytocin is the synthetic form of the naturally occurring pituitary hormone used to initiate or augment UCs Terbutaline is a beta2 adrenergic agonist that may be used to relax smooth muscle of the uterus, esp for PTL and uterine hyperstimulation Naloxone is an opiate antagonist admin to reverse resp distress
Which of the following client statements identifies a knowledge deficit about cast care? 1. "I'll elevate the cast above my heart initially." 2. "I'll exercise my joints above and below the cast." 3. "I can pull out cast padding to scratch inside the cast." 4. "I'll apply ice for 10 minutes to control edema for the first 24 hours."
3. Clients should not pull out cast padding to scratch inside the cast because of the hazard of skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted extremity above the level of the heart to reduce edema and to exercise or move the joints above and below the cast to promote and maintain flexibility and muscle strength. Applying ice for 10 minutes during the first 24 hours helps to reduce edema.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/ 50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/ minute and shallow. The nurse interprets these findings as indicating which of the following? 1. Expected common adverse effects. 2. Hypersensitivity reaction. 3. Possible habituating effect. 4. Hemorrhage from gastrointestinal irritation.
3. Hypotension, tachycardia, and depressed respirations are signs of high levels of ingestion of muscle relaxants, and the client may be developing a habit of taking this drug for a prolonged period. The potential for abuse should be considered when large doses of a muscle relaxant such as carisoprodol are taken for prolonged periods. Expected common adverse effects would include drowsiness, fatigue, lassitude, blurred vision, headache, ataxia, weakness, and gastrointestinal upset. Hemorrhage from gastrointestinal irritation is not associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy? 1. The client adducts the affected leg every 2 hours. 2. The client rolls the affected leg away from the body's midline twice per day. 3. The client performs isometric exercises to the affected extremity three times per day. 4. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/ day.
3. Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Adduction of the leg puts work onto the hip joint as well as altering the pull of traction. Rolling the leg, or external rotation, alters the pull of traction. Additional weight should not be added to traction unless ordered by the physician; it will not prevent muscle atrophy.
The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect? 1. Lack of infection. 2. Reduction in itching. 3. Relief of muscle spasms. 4. Decrease in nervousness.
3. Methocarbamol is a muscle relaxant and acts primarily to relieve muscle spasms. It has no effect on microorganisms, does not reduce itching, and has no effect on nervousness.
A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate? 1. Greater trochanter skin checks. 2. Pin site inspection. 3. Neurovascular checks proximal to the splint. 4. Foot movement evaluation.
3. Neurovascular checks should be performed distal or past the site of the splint, not proximal or above the site of the splint, at least every 4 hours. An injury or compromise to the peripheral nervous innervation or blood flow will reflect a change on the site of the splint after the pathway from the heart and brain. Checking the skin over the greater trochanter is appropriate because the half-ring of the Thomas splint can slide around the greater trochanter area where the traction is applied; it should be checked routinely along with other areas at high risk for pressure necrosis, such as the fibular head, ischial tuberosity, malleoli, and hamstring tendons. Inspecting the pin site is appropriate because any drainage or redness might indicate an infection in the bone in which the pin is inserted. Immediate treatment is imperative to avoid osteomyelitis and possible loss of the limb. Evaluation of the foot for movement is important to obtain neuromuscular-vascular data for assessment in comparison with the baseline data of the affected extremity and with the opposite extremity to detect any compromise of the client's condition.
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room? 1. Transfer the client to a cart with manually suspended traction. 2. Call the surgeon to request an order to temporarily remove the traction. 3. Send the client on his bed with extra help to stabilize the traction. 4. Remove the traction and send the client on a cart.
3. The nurse should send the client to the operating room on his bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.
A mother calls the clinic to report that her 9-month-old infant has diarrhea. Upon further questioning, the nurse determines that the child has mild diarrhea and no signs of dehydration. Which advice is most appropriate to give this mother? 1. "Call back if your infant has 10 stools in 1 day." 2. "Feed your infant clear liquids only." 3. "Continue your infant's normal feedings." 4. Notify your infant's day care of his illness.
3. "Continue your infant's normal feedings." RATIONALE: If an infant has mild diarrhea, his mother should be advised to continue his normal diet and to call back if the diarrhea doesn't stop or if he shows signs of dehydration. There's no need to give the infant clear liquids only. Notifying the day care about the infant's illness is important but doesn't take priority.
An 16-year-old girl is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on her nutritional intake, the nurse should ask: 1. "What activities do you engage in during the day?" 2. "Do you have any allergies to foods?" 3. "Do you like yourself physically?" 4. "What kinds of foods do you like to eat?"
3. "Do you like yourself physically?" RATIONALE: Role and relationship patterns focus on body image and the client's relationship with others, which commonly interrelate with food intake. Therefore, asking the adolescent whether she likes herself physically is appropriate. Questions about activities and food preferences elicit information about health promotion and health protection behaviors, not role and relationship patterns. Questions about food allergies elicit information about health and illness patterns.
A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: 1. "Does your child's ear hurt?" 2. "Does your child have any hearing problems?" 3. "Does your child tug at either ear?" 4. "Does anyone in your family have hearing problems?"
3. "Does your child tug at either ear?" RATIONALE: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.
A 15-year-old adolescent confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response? 1. "We can keep this between you and me, but promise me you won't try anything." 2. "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe." 3. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." 4. "I will need to notify the local authorities of your intentions."
3. "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." RATIONALE: In situations in which a client is a threat to himself, the nurse can't honor confidentiality. Because this adolescent has said he has a specific plan to commit suicide, the nurse must take immediate action to ensure his safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the adolescent that she must do this, while at the same time conveying a sense of caring and understanding. The local authorities needn't be notified in this situation.
A nurse must administer an oral medication to a 3-year-old child. The best way for the nurse to proceed is by saying: 1. "It's time for you to take your medicine right now." 2. "If you take your medicine now, you'll go home sooner." 3. "Here is your medicine. Would you like apple juice or grape drink after?" 4. "See how Jimmy took his medicine? He's a good boy. Now it's your turn."
3. "Here is your medicine. Would you like apple juice or grape drink after?" RATIONALE: Asking the child if he would like apple juice or grape drink is the best approach because involving the child promotes cooperation, and permitting the child to make choices provides a sense of control. Telling a child to take the medicine "right now" could provoke a negative response. Promising that the child will go home sooner could decrease the child's trust in nurses and physicians. Telling the child to "see how Jimmy took his medicine" is inappropriate because it compares one child with another and doesn't encourage cooperation.
To treat a child's atopic dermatitis, a physician orders a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching? 1. "I will spread a thick coat of hydrocortisone cream on the affected area and will wash this area once a week." 2. "I will gently scrape the skin before applying the cream to promote absorption." 3. "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." 4. "I will apply a moisturizing cream sparingly and will wash the affected area frequently."
3. "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." RATIONALE: A parent stating he will avoid using soap and water reflects effective teaching because such washing removes moisture from the horny layer of the skin. Applied in a thin layer, emollient cream holds moisture in the skin, provides a barrier to environmental irritants, and helps prevent infection. Stating he will spread a thick coat of hydrocortisone shows ineffective teaching because topical steroid creams such as hydrocortisone should be applied sparingly as a light film; the affected area should be cleaned gently with water before the cream is applied. Scraping or abrading the skin may actually increase the risk of infection and alter drug absorption. Excessive application of steroidal creams may result in systemic absorption and Cushing's syndrome. Frequent washing dries the skin, making it more susceptible to cracking and further breakdown.
An adolescent with pneumonia is admitted to the pediatric unit. After his parents leave the unit for the evening, he tells the nurse he may have contracted human immunodeficiency virus (HIV). He wants to be tested, but he doesn't want his parents to know about the test. What should the nurse say? 1. "Sorry, you need a parent's permission for the test." 2. "You'll have to talk with the hospital lawyer." 3. "I'll call your physician for the order. No one will tell your parents." 4. "You're too young to have HIV."
3. "I'll call your physician for the order. No one will tell your parents." RATIONALE: Federal laws state that adolescents may be tested for sexually transmitted diseases without their parents' permission. The rules of confidentiality apply to this adolescent; his parents won't be told of his condition unless he agrees. The adolescent doesn't have to speak with a lawyer before the test. HIV can be contracted at any age, even during infancy and childhood.
A mother asks the nurse how to handle her 4-year-old child, who recently started wetting the pants after being completely toilet-trained. The child just started attending nursery school 2 days per week. Which statement by the mother indicates understanding of the situation? 1. "My child hates school." 2. "My child is punishing me for sending him away for a few hours." 3. "My child is most likely regressing back to a behavior that increases his sense of security." 4. "He must have inherited this from my husband. My husband did the same thing when he started nursery school."
3. "My child is most likely regressing back to a behavior that increases his sense of security." RATIONALE: The statement about regression indicates understanding because the stress of starting nursery school may trigger a return to a level of successful behavior from earlier stages of development. A child's skills remain intact, although increased stress may prevent the child from using these skills. The child's behavior isn't an indication that he hates school or wants to punish the mother. Regression isn't a trait that can be inherited.
A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor? 1. "My child has grown 3" in the past 6 months." 2. "My child seems to be napping for longer periods." 3. "My child's abdomen seems bigger, and his diapers are much tighter." 4. "My child's appetite has increased so much lately."
3. "My child's abdomen seems bigger, and his diapers are much tighter." RATIONALE: The most common presenting sign of a Wilms' tumor is abdominal swelling or an abdominal mass. Therefore, the mother's observation that her child's abdomen seems bigger suggests a Wilms' tumor. A rapid increase in length (height) isn't associated with this type of tumor. Although lethargy may accompany a Wilms' tumor, abdominal swelling is a more specific sign. Children with a Wilms' tumor usually have a decreased, not increased, appetite.
The mother of a 12-month-old child expresses concern about the effects of her child's frequent thumb-sucking. After the nurse provides instruction on this topic, which response by the mother indicates that teaching has been effective? 1. "Thumb-sucking should be discouraged at age 12 months." 2. "I'll give my baby a pacifier instead." 3. "Sucking is important to the baby." 4. "I'll wrap the baby's thumb in a bandage."
3. "Sucking is important to the baby." RATIONALE: Stating that sucking is the infant's chief pleasure indicates effective teaching. However, thumb-sucking may cause malocclusion if it persists after age 4. Many fetuses begin sucking on their fingers in utero and, as infants, refuse a pacifier as a substitute, so the mother who states she'll give the infant a pacifier instead requires more teaching. A young child is likely to chew on a bandage, possibly leading to airway obstruction.
A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching? 1. "We should have gone to the physician sooner. Next time, we will." 2. "We'll take our child to the physician's office every week until everything is okay." 3. "We'll go to the physician if our child pulls on the ears or won't lie down." 4. "We're just so glad this is all behind us."
3. "We'll go to the physician if our child pulls on the ears or won't lie down." RATIONALE: The parents indicate full understanding of discharge teaching by repeating the specific, common signs of otitis media in toddlers, such as pulling on the ears and refusing to lie down, and by verbalizing the need for immediate follow-up care if these signs arise. Expressing that they should have gone to the physician sooner doesn't indicate effective teaching because it implies a sense of guilt — a feeling not promoted through teaching. Stating that they'll take the child to the physician's office every week addresses only weekly follow-up care and expressing that they're happy the problem is behind them is unrealistic because the child's condition may recur.
A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? 1. "The baby is gaining weight and doing well. There is no need for solid food yet." 2. "Things have changed a lot since your children were born." 3. "We've found that babies can't digest solid food properly until they're 3 or 4 months old." 4. "We've learned that introducing solid food early leads to eating disorders later in life."
3. "We've found that babies can't digest solid food properly until they're 3 or 4 months old." RATIONALE: Stating that babies can't digest solid food properly is correct because infants younger than 3 or 4 months lack the enzymes needed to digest complex carbohydrates. Saying that there's no need for solid food doesn't address the grandmother's question directly. Saying that things have changed is a cliché that may block further communication with the grandmother. Stating that introducing solid food early leads to eating disorders is incorrect because no evidence suggests that this occurs.
A nurse suspects that a child, age 4, is being neglected physically. To best assess the child's nutritional status, the nurse should ask the parents which question? 1. "Has your child always been so thin?" 2. "Is your child a picky eater?" 3. "What did your child eat for breakfast?" 4. "Do you think your child eats enough?"
3. "What did your child eat for breakfast?" RATIONALE: The nurse should ask what the child ate for breakfast in order to obtain objective information about the child's nutritional intake. Asking if the child has always been so thin, if he's a picky eater, or if he eats enough would elicit subjective replies that would be open to interpretation.
When assessing an 18-month-old child, the nurse determines that the child's height and weight fall below the 5th percentile on the growth chart. In all previous visits, the child's height and weight fell between the 30th and 40th percentiles. The child's mother expresses concern about the slowed growth rate. How should the nurse respond? 1. "What do you feed your child?" 2. "Don't worry. Your child is bound to have a growth spurt soon." 3. "Your child's height and weight must be checked again in 1 month." 4. "How much weight did you gain when you were pregnant with this child?"
3. "Your child's height and weight must be checked again in 1 month." RATIONALE: Although the growth rate usually slows between ages 1 and 3, it normally doesn't drop as dramatically as this child's. Therefore, the nurse should advise the mother to have the child's growth rate monitored frequently, such as every month. Asking the mother what she feeds her child implies that the mother is at fault for the child's slow growth. Telling the mother not to worry is inappropriate because it doesn't address the mother's concern about the child. Asking about pregnancy weight gain is inappropriate because maternal weight gain during pregnancy wouldn't affect a child's growth rate at 18 months.
A nurse is preparing to administer short-acting insulin to a child with type 1 diabetes. When should the nurse measure the child's blood glucose level? 1. Immediately before administering insulin 2. 15 minutes after administering insulin 3. 1 hour after administering insulin 4. 4 hours after administering insulin
3. 1 hour after administering insulin RATIONALE: Short-acting insulins peak in 30 minutes to 2 hours after administration. Therefore, the nurse should check the child's blood glucose level during this period, such as 1 hour after administration. Measuring the glucose level immediately before or 15 minutes after administering insulin would be too soon. Waiting until 4 hours after administering insulin would be too late to obtain an accurate reading.
A mother brings her child, age 3, to the clinic for an annual checkup. After plotting the child's height and weight on a pediatric growth chart, the nurse identifies which percentile range as normal? 1. 25th to 75th percentile 2. 50th to 100th percentile 3. 5th to 95th percentile 4. 10th to 100th percentile
3. 5th to 95th percentile RATIONALE: Height and weight measurements that fall between the 5th and 95th percentiles represent normal growth for most children. Children whose measurements fall outside this range require further evaluation.
48. The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease. 3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.
3. A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.
Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric (NG) tube? 1. Abdominal X-rays 2. Injection of a small amount of air while listening with a stethoscope over the abdominal area 3. A check of the pH of fluid aspirated from the tube 4. Visualization of the measurement mark on the tube made at the time of insertion
3. A check of the pH of fluid aspirated from the tube RATIONALE: Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times a day on a daily basis. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines.
An 18-month-old boy is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child? 1. A concave abdomen 2. Bulges in the groin area 3. A protuberant abdomen 4. A palpable abdominal mass
3. A protuberant abdomen RATIONALE: The nurse would expect to find a protuberant abdomen caused by the presence of fat, bulky stools; undigested food; and flatus, which are associated with celiac disease. A concave abdomen, bulges in the groin area, and a palpable abdominal mass aren't associated with celiac disease.
Your client has a pressure ulcer over the sacral area that is believed to be due to shearing force. The client's family asks you to explain shearing force. You would be most accurate if you tell the family that shearing force involves: 1. A tearing of the muscle tissue due to a considerable downward force. 2. A sudden break in skin integrity due to being pulled against the bed linens. 3. A superficial skin fold getting pinched, and tissues irritated by the pressure. 4. Superficial skin surface relatively unmoving in relation to the bed surface.
3. A superficial skin fold getting pinched, and tissues irritated by the pressure; Shearing force is a combination of friction and pressure with skin surface unmoving in relation to the bed surface, while deeper tissue attached to the skeleton tends to move with the body.
3. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action net? a. Reassess the client b. Conduct a staff meeting to describe the fall c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall
3. A- After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.
A nurse is reviewing a care plan for an adolescent girl who's receiving chemotherapy for leukemia who was admitted for pneumonia. The adolescent's platelet count is 50,000 μl. Which item in the care plan should the nurse revise? 1. Keep a sign over the bed that reads "NO NEEDLE STICKS AND NOTHING PER RECTUM." 2. Use two peripheral I.V. intermittent infusion devices, one for blood draws and one for infusions. 3. Administer oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula. 4. Use a tympanic membrane sensor to measure her temperature at the bedside.
3. Administer oxygen at a rate of 4 L/minute using a nonhumidified nasal cannula. RATIONALE: Oxygen should be humidified to assure that irritation of the mucosa doesn't occur. This adolescent's platelet level is decreased, so she's at risk for bleeding. The nose is a vascular region that can bleed easily if the mucosa is dried by the oxygen. Therefore, the nurse should revise the care plan to reflect use of humidified oxygen. A sign to remind others to avoid needle sticks and to not give anything via the rectum, the presence of two peripheral I.V.s, and the use of a tympanic temperature device are all aspects of care that would decrease the adolescent's risk of bleeding.
44. The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the client's neurological status every hour. 2. Monitor the client's heart rhythm via telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare to administer a glucocorticosteroid orally.
3. Administering an anticonvulsant medication by intravenous push requires the nurse to have an order or confer with another member of the health-care team.
A nurse is making assignments for the infant unit. The shift's team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN? 1. An infant being discharged to home following placement of a gastrostomy tube 2. An infant just returned from the postanesthesia care unit who requires hourly assessment of vital signs 3. An infant requiring abdominal dressing changes for a wound infection 4. An infant with agonal respirations who is receiving palliative care
3. An infant requiring abdominal dressing changes for a wound infection RATIONALE: The infant requiring dressing changes is within an LPN's scope of practice. This care has a predictable outcome. Client and family teaching — such as how to care for a gastrostomy tube — is an RN's responsibility. A client care assistant can be assigned to obtain vital signs and report the findings to the supervising RN. Because the outcome of the infant with agonal respirations is unpredictable, the RN shouldn't delegate his care to the LPN.
A chronically ill school-age child is most vulnerable to which stressor? 1. Mutilation anxiety 2. Anticipatory grief 3. Anxiety over school absences 4. Fear of hospital procedures
3. Anxiety over school absences RATIONALE: The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.
Which item in the care plan for a toddler with a seizure disorder should a nurse revise? 1. Padded side rails 2. Oxygen mask and bag system at bedside 3. Arm restraints while asleep 4. Cardiorespiratory monitoring
3. Arm restraints while asleep RATIONALE: The nurse should revise a care plan that includes restraints. Restraints should never be used on a child with a seizure disorder because they could harm him if a seizure occurs. Padded side rails will prevent the child from injuring himself during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.
To establish a good interview relationship with an adolescent, which strategy is most appropriate? 1. Asking personal questions unrelated to the situation 2. Writing down everything the teen says 3. Asking open-ended questions 4. Discussing the nurse's own thoughts and feelings about the situation
3. Asking open-ended questions RATIONALE: Open-ended questions allow the adolescent to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he's being interrogated with unnecessary questions. Writing everything down during the interview can be a distraction and doesn't allow the nurse to observe how the adolescent behaves. Discussing the nurse's thoughts and feelings may bias the assessment and is inappropriate when interviewing any client.
When performing a physical examination on a neonate, the nurse notes low-set ears. What action should the nurse perform next? 1. Call the pediatrician for an immediate evaluation of the infant. 2. Note the findings in the medical record. 3. Assess the neonate to determine if other apparent abnormalities are present. 4. Order an ultrasound of the head to determine if the brain is normal.
3. Assess the neonate to determine if other apparent abnormalities are present. RATIONALE: Although low-set ears are an abnormal finding, the presence of this abnormality by itself isn't cause for immediate concern. The nurse should continue to assess the neonate to determine if other abnormalities are present. It's appropriate to note the abnormality in the medical record; however, it's even more important to continue the assessment. It's outside the scope of nursing practice to order a diagnostic test, such as an ultrasound, and there's no indication for this test.
Which is the priority intervention for a preschool child with epiglottiditis and a deteriorating respiratory status? 1. Administering oxygen by face mask 2. Administering parenteral antibiotics 3. Assisting with intubation 4. Monitoring the electrocardiogram for arrhythmias
3. Assisting with intubation RATIONALE: The most important intervention for a child with epiglottiditis is airway management because children are at high risk for developing abrupt airway obstruction. Therefore, intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they will never allow a mask to stay in place. Provide humidified "blow-by" oxygen administered by the parent if possible. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management.
A nurse is caring for an 8-year-old child with acute asthma exacerbation. Which situation would be of greatest concern to the nurse? 1. The child's respiratory rate is now 24 breaths/minute. 2. Recent blood gas analysis indicates an oxygen saturation of 95%. 3. Before a respiratory therapy treatment, wheezing isn't heard on auscultation. 4. The child's mother reports that the child sometimes forgets to take the inhalers.
3. Before a respiratory therapy treatment, wheezing isn't heard on auscultation. RATIONALE: Typically, before a respiratory therapy treatment, wheezing has increased and the child has increased respiratory distress. No wheezing on auscultation is an indication that the child isn't moving air in and out and is in respiratory distress. A respiratory rate of 24 breaths/minute in an 8-year-old child is normal. An oxygen saturation of 95% is somewhat of a concern, possibly indicating that the child needs oxygen or needs to clear the airways. However, this finding is a lower priority than no wheezing on auscultation. The fact that the mother makes the 8-year-old child responsible for taking medications is of concern and needs to be investigated, but this isn't as important at this time as the lack of wheezing.
When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness? 1. No motor or verbal response to noxious (painful) stimuli 2. Remains in a deep sleep; responsive only to vigorous and repeated stimulation 3. Can be roused with stimulation 4. Limited spontaneous movement; sluggish speech
3. Can be roused with stimulation RATIONALE: The child is obtunded if he can be aroused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic.
A parent brings a toddler, age 19 months, to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? 1. Closed anterior fontanel and open posterior fontanel 2. Open anterior fontanel and closed posterior fontanel 3. Closed anterior and posterior fontanels 4. Open anterior and posterior fontanels
3. Closed anterior and posterior fontanels RATIONALE: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
Which action illustrates the responsibilities of a pediatric case manager on the pediatric orthopedic unit? 1. Providing direct child care 2. Writing orders in the medical chart 3. Consulting with health care providers to make sure the child is following the critical pathway 4. Assisting the orthopedic surgeon in the operating room
3. Consulting with health care providers to make sure the child is following the critical pathway RATIONALE: Case managers follow a group of clients, ensuring that their care follows the appropriate critical pathway. These pathways contain a timeline designed to coordinate the multidisciplinary team toward a common goal of providing a short, safe, and healthy length of stay in the hospital. Registered nurses handle most of the direct bedside client care, whereas physicians and nurse practitioners are responsible for writing medical orders. The circulating nurse and scrub nurse work in the operating room, assisting the orthopedic surgeon.
A 9-year-old child presents to a school nurse with complaints of arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate? 1. Arrange for the child to speak with the school psychologist as soon as possible. 2. Arrange for a meeting with the nurse, psychologist, school administrators, and the child's parents. 3. Contact the authorities immediately. 4. Contact an ambulance to transport the child to the emergency department.
3. Contact the authorities immediately. RATIONALE: When a nurse suspects abuse, she must contact the authorities immediately. Although speaking with the school psychologist may be helpful, the nurse shouldn't delay contacting the authorities. A family meeting might provide additional information, but the nurse must allow the authorities to investigate suspected abuse before confronting the child's parents. Because the child isn't in imminent distress, there's no need for an ambulance.
Which nursing activity supports the principles of palliative care for a dying infant and his family? 1. Maintaining routines and structure for the infant and his family 2. Clustering care activities to provide as much rest as possible for the infant 3. Creating a therapeutic, homelike environment for the infant and his family 4. Minimizing noise and disruption to decrease stress for the infant
3. Creating a therapeutic, homelike environment for the infant and his family RATIONALE: The goal of palliative care is to make the infant and his family as comfortable as possible. Maintaining routines and structure doesn't support the principles of palliative care. Clustering care activities may allow the infant more rest, but this action isn't a principle of palliative care. Minimizing noise and disruption isn't specifically related to palliative care.
A mother brings her 4-month-old infant to the clinic for a wellness checkup. Which immunizations should the infant receive? 1. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP), inactivated polio virus (IPV), rotavirus, and measles-mumps-rubella (MMR) 2. Haemophilus influenzae type B (Hib), rotavirus, DTaP, and IPV 3. DTaP, IPV, Hib, hepatitis B, and pneumococcal conjugate vaccine (PCV) 4. DTaP, hepatitis B, Hib, and varicella
3. DTaP, IPV, Hib, hepatitis B, and pneumococcal conjugate vaccine (PCV) RATIONALE: DTaP, IPV, Hib, hepatitis B, and PCV are administered at ages 2 and 4 months. The MMR vaccine is typically administered at age 12 to 15 months. Rotavirus vaccine is no longer recommended because of the associated risk of intussusception. The varicella vaccine is commonly administered between ages 12 and 18 months.
When a nurse assesses a 2-year-old child with suspected dehydration, which condition should be reported to the physician immediately? 1. Irritability for the past 12 hours 2. Capillary refill less than 2 seconds 3. Decreased blood pressure 4. Tachycardia, dry skin, and dry mucous membranes
3. Decreased blood pressure RATIONALE: The nurse should immediately report decreased blood pressure because it's a late sign of severe dehydration. This delayed decrease occurs because compensatory mechanisms in children are able to sustain blood pressure in the low-normal range for some time. Irritability, capillary refill less than 2 seconds, tachycardia, dry skin, and dry mucous membranes are all early signs of dehydration.
A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis should be the highest priority? 1. Risk for injury related to unsteady gait 2. Disturbed body image 3. Deficient fluid volume (hemorrhage) 4. Impaired physical mobility
3. Deficient fluid volume (hemorrhage) RATIONALE: Deficient fluid volume (hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage. Risk for injury related to unsteady gait isn't indicated in this situation. Disturbed body image isn't a concern because the adolescent doesn't have a visible injury. Although the adolescent may be placed on bed rest for 5 to 7 days, Impaired physical mobility isn't the priority nursing diagnosis.
41. The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.
3. During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.
Which of the following terms is used to describe the thinning and shortening of the cervix that occurs just before and during labor? 1. Ballottement 2. Dilation 3. Effacement 4. Muliparous
3. Effacement effacement is cervical shortening and thinning while dilation is widening of the cervix both facilitate opening the cervix in prep for delivery. Ballottement is the ability of another individual to move the fetus by externally manipulating the maternal abdomen. A ballotable fetus hasn't yet engaged in the maternal pelvis. Multiparous refers to a woman who has had previous live births.
A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first? 1. Perform passive range-of-motion (ROM) exercises on the wrist. 2. Massage the wrist and apply a warm compress. 3. Elevate the affected arm and apply ice to the injury site. 4. Notify the physician.
3. Elevate the affected arm and apply ice to the injury site. RATIONALE: Severe joint pain in a child with hemophilia indicates bleeding; therefore, the nurse should first elevate the affected extremity and apply ice to the injury site to promote vasoconstriction. ROM exercises may worsen discomfort and bleeding. Massage and warm compresses also may increase bleeding. The nurse should notify the physician only after taking measures to stop the bleeding.
A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? 1. Applying ice to the foot 2. Massaging the toes 3. Elevating the foot of the bed 4. Placing the child on his right side
3. Elevating the foot of the bed RATIONALE: To relieve edema of the toes, the most appropriate reaction is to raise the affected extremity above heart level such as by elevating the foot of the bed. Applying ice, massaging the toes, and placing the child on his right side wouldn't reduce swelling.
A client hospitalized for premature labor tells the nurse she's having occasional contractions. Which of the following nursing interventions would be the most appropriate? 1. Teach the client the possible complications of premature birth. 2. Tell the clients to walk to see if she can get rid of the contractions. 3. Encourage her to empty her bladder and drink plenty of fluids, IV fluids 4. Notify anesthesia for immediate epidural placement to relieve the pain associated with contractions.
3. Encourage her to empty her bladder and drink plenty of fluids, IV fluids An empty bladder and adequate hydration may help decrease or stop labor contractions. Walking may encourage contractions to become stronger. Teaching the potential complications is likely to increase the clients anxiety rather than relax her It would be inappropriate to call anesthesia
When a toddler with croup is admitted to the facility, a physician orders treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What should the nurse do to gain the child's cooperation with the treatment? 1. Turn off the mist so the noise doesn't frighten the toddler. 2. Let the toddler sit on the parent's lap next to the mist tent. 3. Encourage the parent to stand next to the crib and stay with the child. 4. Put the side rail down so the toddler can get into and out of the crib unaided.
3. Encourage the parent to stand next to the crib and stay with the child. RATIONALE: The nurse should encourage the parent to stand next to the crib and stay with the child. This approach promotes compliance with treatment while minimizing the toddler's separation anxiety. Because the mist helps thin secretions and make them easier to clear, turning off the mist or letting the toddler sit next to the mist tent defeats the treatment's purpose. To prevent falls, the nurse should keep the side rails up and shouldn't permit the toddler to climb into and out of the crib.
The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which behavior indicates acceptance? 1. Failure to recognize the seriousness of the girl's condition despite physical evidence 2. Intellectualization about the illness in areas unrelated to the girl's condition 3. Expression of feelings, such as sorrow and anger, about the girl's condition 4. Avoidance of staff, family members, or the girl herself.
3. Expression of feelings, such as sorrow and anger, about the girl's condition RATIONALE: The ability to express feelings and relate them to the diagnosis is the first step in accepting the situation. Failing to recognize the seriousness of the girl's condition despite physical evidence, intellectualizing about the illness in areas unrelated to the girl's condition, and avoiding staff, family members, or the girl herself are all avoidance behaviors that represent a parent's inability to cope with the situation.
A 6-year-old child has tested positive for West Nile virus infection. The nurse suspects the child has the severe form of the disease when she recognizes which signs and symptoms? 1. Fever, rash, and malaise 2. Anorexia, nausea, and vomiting 3. Fever, muscle weakness, and change in mental status 4. Fever, lymphadenopathy, and rash
3. Fever, muscle weakness, and change in mental status RATIONALE: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise, anorexia, nausea and vomiting, and lymphadenopathy suggest the mild, not severe, form of West Nile virus infection.
A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority? 1. Administering platelets as ordered 2. Taking measures to prevent infection 3. Frequently assessing the child's level of consciousness (LOC) 4. Discussing a safe play environment with the parents
3. Frequently assessing the child's level of consciousness (LOC) RATIONALE: In hemophilia, one of the factors required for blood clotting is absent, significantly increasing the risk of hemorrhage after injury. Therefore, the nurse must assess the child frequently for signs and symptoms of intracranial bleeding, such as an altered LOC, slurred speech, vomiting, and headache. To manage hemophilia, the absent blood clotting factor is replaced via I.V. infusion of factor, cryoprecipitate, or fresh frozen plasma; this may be done prophylactically or after a traumatic injury. Platelet transfusions aren't necessary. Clients with hemophilia aren't at increased risk for infection. Discussing a safe play environment with the parents is important but isn't the highest priority.
Craniocerebral injury in a child differs substantially from craniocerebral trauma in an adult. Which statement identifies a difference between children and adults that could produce a life-threatening complication for a child? 1. Cerebral tissues in children are softer, thinner, and more flexible. 2. A child's skull can expand more than an adult's can. 3. Greater portions of a child's blood volume flows to the head. 4. Hematomas in children can include subdural, epidural, and intracerebral.
3. Greater portions of a child's blood volume flows to the head. RATIONALE: If hemorrhage is associated with a head injury and it goes undetected, a child may experience hypovolemic shock because a large portion of a child's blood volume goes to the head. In children, cerebral tissues are softer, thinner, and more flexible — conditions that actually permit diffusion of the impact. Because a child's skull can expand more than an adult's can, a greater amount of posttraumatic edema can occur without evidence of neurologic deficits. Subdural, epidural, and intracerebral hematomas are the different types of head injury that can occur in children and adults.
Which technique is most effective in preventing nosocomial infection transmission when caring for a preschooler? 1. Client isolation 2. Standard precautions 3. Hand washing 4. Needleless syringe system
3. Hand washing RATIONALE: Hand washing is the single most important measure for preventing infection transmission. Isolating the child and using infection control precautions are required for certain diseases, such as varicella, diphtheria, mumps, pertussis, measles, and meningitis. Standard precautions, which include hand washing, are guidelines for treating all clients as potentially infectious. A needleless syringe system will prevent transmission through needle sticks but not from body fluid contact.
A preschool-age child scheduled for surgery in the morning is admitted to the facility for the first time. Which nursing action would ease the child's anxiety? 1. Beginning preoperative teaching as soon as possible 2. Explaining that the child will be "put to sleep" during the operation and will feel nothing 3. Having the child act out the surgical experience using dolls and medical equipment 4. Explaining preoperative and postoperative procedures step by step
3. Having the child act out the surgical experience using dolls and medical equipment RATIONALE: Having the child act out the surgical experience using dolls and medical equipment would ease anxiety and give the nurse an opportunity to clarify the child's misconceptions. Preschoolers have a limited concept of time, so the nurse should provide preoperative teaching just before surgery rather than starting it as soon as possible; also, a delay between teaching and surgery may heighten anxiety by giving the child a chance to worry or fantasize. The nurse should avoid using such phrases as "put to sleep" because these may have a dual or negative meaning to a young child. Long explanations are inappropriate for the preschooler's developmental level and may increase anxiety.
Which relaxation strategy would be effective for a school-age child to use during a painful procedure? 1. Having the child keep his eyes shut at all times 2. Having the child hold his breath and not yell 3. Having the child take a deep breath and blow it out until told to stop 4. Being honest with the child and telling him the procedure will hurt a lot
3. Having the child take a deep breath and blow it out until told to stop RATIONALE: Having the child take a deep breath and blow it out is a form of distraction and will help the child cope better with the procedure. A child may prefer to keep his eyes open, not shut, during a procedure so he can see what is going on and can anticipate what is going to happen. Letting a child yell during a procedure is a form of helpful distraction. In addition, holding the breath isn't beneficial and could have adverse effects (such as feeling dizzy or faint). The nurse should prepare a child for a procedure by using nonpain descriptors and not suggesting pain. For example, the nurse might say, "Sometimes this feels like pushing or sticking, and sometimes it doesn't bother children at all."
Which statement, if made by the client or family member, would indicate the need for further teaching? 1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. 2. Putting foam pads under the heels or other bony areas can help decrease pressure. 3. If a person cannot turn himself in bed, someone should help them change position q4h. 4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.
3. If a person cannot turn himself in bed, someone should help them change position q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires additional teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.
What advice should a nurse give to the parents of a 2-year-old child who frequently throws temper tantrums? 1. Move the toddler to a different setting. 2. Allow the toddler more choices. 3. Ignore the behavior when it happens. 4. Give into the toddler's demands.
3. Ignore the behavior when it happens. RATIONALE: Ignoring tantrums is the best advice because paying attention to the undesirable behavior can reinforce it. Changing settings can actually increase the tantrum behavior. Allowing the toddler more choices may also increase tantrum behavior if the toddler is unable to follow through with choices. It's ill-advised to give into the toddler's demands because doing so only promotes tantrum behavior.
A high-risk adolescent is given a tuberculin intradermal skin test to detect tuberculosis infection. How long after the test is administered should the results be evaluated? 1. Immediately afterward 2. Within 24 hours 3. In 48 to 72 hours 4. After 5 days
3. In 48 to 72 hours RATIONALE: Tuberculin skin tests are tests of delayed hypersensitivity. If the test results are positive, a reaction should appear in 48 to 72 hours. Immediately afterward and within 24 hours of administration are too soon to observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction that occurred may no longer be visible.
According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion
3. Industry versus inferiority RATIONALE: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence.
At the health clinic, a sexually active 15-year-old girl tells a nurse she's worried that her parents may find out about her sexual activity. "They would never approve," she says. The nurse should formulate which nursing diagnosis? 1. Delayed growth and development related to sexual activity 2. Impaired social interaction related to boyfriend's expectations 3. Ineffective sexuality patterns related to parent's expectations 4. Fear related to boyfriend's expectations
3. Ineffective sexuality patterns related to parent's expectations RATIONALE: This girl is expressing concerns about the conflict between her parent's expectations and her own desires. Sexual activity is a normal experimental pattern for many adolescents, but she verbalizes parental expectations against this behavior. No evidence suggests she's having a conflict with her boyfriend, delayed growth, or problems with social interactions.
Which interview strategy contributes to a poor nurse-adolescent relationship? 1. Maintaining objectivity by avoiding assumptions, judgments, and lectures 2. Beginning with less-sensitive issues and proceed to more-sensitive ones 3. Interviewing adolescents with their parents present 4. Asking open-ended questions and moving to more directive questions when possible
3. Interviewing adolescents with their parents present RATIONALE: When possible, adolescents should be interviewed without their parents present to ensure confidentiality and privacy. Interviewing adolescents with their parents present hinders the formation of the nurse-adolescent relationship. Avoiding assumptions, judgments, and lectures will increase the adolescents' comfort in disclosing sensitive information. Begin with less-sensitive questions so the adolescents won't feel threatened and uncomfortable and become uncooperative during the interview. Ask open-ended questions to give adolescents opportunities to share their psychosocial context.
A 4-year-old has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first? 1. Notify the physician because the child has an NG tube. 2. Immediately give the child an antiemetic I.V. 3. Irrigate the NG tube to ensure patency. 4. Encourage the mother to calm the child down.
3. Irrigate the NG tube to ensure patency. RATIONALE: The nurse should first irrigate the NG tube because if the tube isn't draining properly or is kinked, the child will experience nausea. There's no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the mother to calm the child is always a good intervention but isn't the first thing to do in this case.
When assessing a child with hemophilia, the nurse identifies which condition as an early sign of hemarthrosis? 1. Decreased peripheral pulses 2. Active bleeding 3. Joint stiffness 4. Hematuria
3. Joint stiffness RATIONALE: Joint stiffness is an early sign of hemarthrosis. Hemarthrosis doesn't affect pulses and bleeding into the joints can't be observed directly. Hematuria is incorrect because this sign indicates bleeding in the urinary tract.
A 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? 1. Apply a warm compress to the injured shoulder. 2. Ask him to demonstrate full range of motion of his left arm. 3. Keep him in a comfortable position and apply ice to the injured shoulder. 4. Give him a nonopioid analgesic for pain.
3. Keep him in a comfortable position and apply ice to the injured shoulder. RATIONALE: Ice should be applied first to reduce swelling and pain. The client should also be helped into a comfortable position. The nurse shouldn't apply warm compresses because it may increase swelling and cause bleeding into the injured tissue. Demonstrating full range of motion of the left arm may cause further damage to the injured area. In the emergency department, the nurse must have a physician's order to administer an analgesic.
A nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children? 1. Heart 2. Lungs 3. Kidneys 4. Liver
3. Kidneys RATIONALE: The kidneys are most responsible for drug excretion in children. Less commonly, some drugs may be excreted via the lungs or liver. Drugs are never excreted by the heart in children or adults.
An adolescent admitted with sickle cell anemia is most at risk for developing which complication? 1. Swelling of the hands and feet 2. Petechiae 3. Leg ulcers 4. Hemangiomas
3. Leg ulcers RATIONALE: In sickle cell anemia, sickling of red blood cells leads to increased blood viscosity and impaired circulation. Diminished peripheral circulation makes the adolescent or adult with sickle cell anemia susceptible to chronic leg ulcers. In children younger than age 2 who have sickle cell anemia (not adolescents), swelling of the hands and feet (hand-foot syndrome) commonly occurs during a vaso-occlusive crisis as a result of infarction of short tubular bones. Petechiae aren't associated specifically with sickle cell anemia. Hemangiomas, benign tumors of dilated blood vessels, aren't linked to sickle cell anemia.
A 17-year-old adolescent with acute lymphocytic leukemia is discharged with written information about chemotherapy administration and his outpatient appointment schedule. He now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve his compliance, the nurse should include which intervention in the care plan? 1. Emphasizing the long-term consequences of noncompliance 2. Reprimanding the adolescent for failing to comply with his treatment 3. Letting the adolescent participate in his planning and scheduling of treatments 4. Threatening to discontinue care if he doesn't comply
3. Letting the adolescent participate in his planning and scheduling of treatments RATIONALE: Because the adolescent is striving for independence, health care providers should promote self-reliance whenever possible, such as by letting him participate in planning and scheduling his treatments. He can help establish realistic goals and evaluation outcomes as well as help schedule procedures and chemotherapy doses to minimize lifestyle disruptions. Adolescents are oriented in the present and have relatively little concern for the long-term consequences of their behavior. Reprimanding him or threatening to discontinue care isn't likely to improve compliance and isn't in his best interest.
During the last 6 weeks of gestation, which of the following tests isnt used to determine FWB? 1. BPP 2. NST 3. Maternal blood count 4. FM count
3. Maternal Blood count - evaluates maternal, not fetal well being BPP - uses US to eval fetal body movements, breathing movements, muscle tone, reactive fetal cardiac rate, amniotic fluid volume NST - evals the FHR for accels during FM FM - counts are used during the last trimester to obtain a rough index of fetal health - the number of FM are counted at diff times throughout the day and then charted to detect any change in overall activity over a number of days
A 6-year-old child is admitted to the pediatric unit for evaluation of recurrent abdominal pain. The child has been admitted to the pediatric unit with similar complaints several times in the past few months. The child's symptoms are vague, yet his mother provides detailed information about the problem. The nurse is suspicious of the situation. What should the nurse do next? 1. Request that the parent leave the hospital unit immediately. 2. Ask to speak with the child without the parent being present. 3. Notify the physician and request assistance from the interdisciplinary team. 4. Contact the authorities immediately.
3. Notify the physician and request assistance from the interdisciplinary team. RATIONALE: The child's clinical presentation and the mother's behavior suggest Munchausen syndrome by proxy, a condition in which an individual fabricates or induces symptoms of a disorder in another person. Suspicion of this condition mandates a coordinated evaluation by the health care team. Rather than asking the parent to leave, the nurse should establish a rapport with her. Doing so will prevent the parent from becoming suspicious and leaving the health care organization, which would potentially allow the cycle to continue. The nurse must contact authorities when she obtains additional evidence.
A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? 1. Registered dietitian 2. Physical therapist 3. Occupational therapist 4. Nursing assistant
3. Occupational therapist RATIONALE: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn't trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn't trained in modifying utensils.
An adolescent admitted to the adolescent unit with pain caused by sickle cell crisis. Who should be consulted first about this adolescent's care? 1. Nutritionist 2. Physical therapist 3. Pediatric pain specialist 4. Case manager
3. Pediatric pain specialist RATIONALE: Children and adolescents hospitalized with sickle cell crisis are commonly in excruciating pain. Therefore, the pediatric pain specialist should be consulted first to help relieve the adolescent's pain. The adolescent also requires hydration with I.V. fluids, but consulting a nutritionist isn't important at this time. Bed rest is commonly ordered to minimize energy expenditure and oxygen demand; therefore, consulting a physical therapist isn't necessary at this time. It isn't necessary to consult the case manager first; pain relief is most important at this time.
When assessing a toddler, age 18 months, the nurse should interpret which reflex as a sign of a neurologic dysfunction? 1. Positive gag reflex 2. Positive tonic neck reflex 3. Positive Babinski's reflex 4. Positive corneal reflex
3. Positive Babinski's reflex RATIONALE: A nurse should interpret Babinski's reflex as a sign of neurologic dysfunction because this reflex should disappear by age 12 months. The gag reflex, tonic neck reflex, and corneal reflex are normal findings for a toddler.
A child, age 4, is hospitalized because of alleged sexual abuse. What is the best nursing intervention for this child? 1. Avoiding touching the child 2. Preventing the suspected abuser from visiting the child 3. Providing play situations that allow disclosure 4. Discouraging the child from talking about what happened
3. Providing play situations that allow disclosure RATIONALE: The best nursing intervention is to provide play situations because through certain play situations, a sexually abused child can disclose information without actually talking about himself or herself. Avoiding touch would be inappropriate because an abused child needs to be touched and cared for like any other hospitalized child. The nurse can't restrict visitation unless the threat of repeated abuse exists while the child is hospitalized. The nurse shouldn't discourage discussion of the abuse if the child feels able to talk about it.
A toddler is having a tonic-clonic seizure. What should the nurse do first? 1. Restrain the child. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing.
3. Remove objects from the child's surroundings. RATIONALE: During a seizure, the nurse's first priority is to protect the child from injury caused by uncontrolled movements. Therefore, the nurse must first remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure isn't appropriate because it may cause injury. When the seizure stops, the nurse should then check for breathing and, if indicated, initiate rescue breathing.
A 4-year-old child is being treated for status asthmaticus. His arterial blood gas analysis reveals a pH of 7.28, PaCO2 of 55 mm Hg, and HCO3− of 26 mEq/L. What condition do these findings indicate? 1. Respiratory alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Metabolic alkalosis
3. Respiratory acidosis RATIONALE: A pH less than 7.35 and a PaCO2 greater than 45 mm Hg indicate respiratory acidosis. Status asthmaticus is a medical emergency that's characterized by respiratory distress. Persistent hypoventilation leads to the accumulation of carbon dioxide, resulting in respiratory acidosis.
Parents of a preschooler with chickenpox ask the nurse about measures to make their child comfortable. The nurse instructs the parents to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? 1. Guillain-Barré syndrome 2. Rheumatic fever 3. Reye's syndrome 4. Scarlet fever
3. Reye's syndrome RATIONALE: Research shows a correlation between the use of aspirin in children with flulike symptoms and the development of Reye's syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever.
During a well-baby visit, a mother asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first? 1. Applesauce 2. Egg whites 3. Rice cereal 4. Yogurt
3. Rice cereal RATIONALE: The nurse should instruct her to introduce rice cereal first because it's easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt and, finally, meat. Egg whites shouldn't be given until age 9 months because they may trigger a food allergy.
A child, age 3, is hospitalized for treatment of Kawasaki disease. Which of these nursing diagnoses should receive priority in the child's care plan: 1. Self-care deficit 2. Diarrhea 3. Risk for injury 4. Caregiver role strain
3. Risk for injury RATIONALE: Kawasaki disease, which affects young children, is characterized by acute systemic vasculitis. Risk for injury should receive priority because this inflammation of blood vessels leads to platelet accumulation and the formation of thrombi or obstruction in the heart and blood vessels. Approximately 10 days after the onset of the disease process, the platelet count rises and thrombi may form in the coronary arteries, leading to a myocardial infarction. The nurse must monitor the child closely for chest pain, cyanosis or pallor, and changes in the blood pressure. Diarrhea isn't a symptom of Kawasaki disease. Although Self-care deficit and Caregiver role strain may be appropriate diagnoses for this child, they don't take priority over Risk for injury.
While preparing to discharge a 9-month-old infant who's recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant's dietary and fluid requirements. The nurse should include which other topic in the teaching session? 1. Nursery schools 2. Toilet training 3. Safety guidelines 4. Preparation for surgery
3. Safety guidelines RATIONALE: Reinforcing safety guidelines is appropriate because such anticipatory guidance helps prevent many accidental injuries. For parents of a 9-month-old infant, it's too early to discuss nursery schools or toilet training. Because surgery isn't used to treat gastroenteritis, this topic is inappropriate.
A dehydrated infant is receiving I.V. therapy. The mother tells the nurse she wants to hold her infant but is afraid this might cause the I.V. line to become dislodged. What should the nurse do? 1. Tell the mother it's best not to move the infant now. 2. Inform the mother that only a nurse should hold the infant during I.V. therapy. 3. Show the mother how to hold the infant properly. 4. Advise the mother to let the infant lie quietly in bed.
3. Show the mother how to hold the infant properly. RATIONALE: Infants with I.V. lines should be held with care. The nurse should encourage and show the mother how to hold the infant properly and teach her about I.V. care measures to enhance her confidence and skill. The nurse should encourage the mother to participate in the child's care whenever possible, not just during I.V. therapy. There's no need for the infant to have to lie quietly in bed.
A 6-year-old child was admitted to the pediatric unit after sustaining a broken leg in a motor vehicle accident. Which specialist would be most important to involve in this child's care during hospitalization? 1. Home care nurse 2. Nutritionist 3. Social worker 4. Infectious disease nurse
3. Social worker RATIONALE: The nurse should collaborate with the social worker to provide care for the child involved in a motor vehicle accident. After such a traumatic life event, this child's care will involve dealing with his emotional health as well as his physical recovery. Home health care isn't usually needed for this type of injury, and nutrition isn't a top priority problem for this child. There's nothing to suggest that the infectious disease nurse is required to care for this child.
A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next? 1. After starting the fluids, contact the maintenance department and request a pump inspection. 2. Hang the fluids without the pump, carefully calculating the drip rate by visual inspection. 3. Take the pump out of commission and locate a pump with a valid inspection sticker. 4. Begin the infusion of the fluids while looking for a pump with a valid inspection sticker.
3. Take the pump out of commission and locate a pump with a valid inspection sticker. RATIONALE: The nurse shouldn't use any equipment that doesn't have current inspection information. The pump could malfunction, causing harm to the patient. The nurse should remove the pump from service and locate a pump with the proper inspection information.
Which approach by a nurse is the best for trying to take a crying toddler's temperature? 1. Ignore the crying and screaming. 2. Tell the mother not to hold the child. 3. Talk to the mother first and then to the toddler. 4. Bring extra help so it can be done quickly.
3. Talk to the mother first and then to the toddler. RATIONALE: When dealing with a crying toddler, the best approach is to talk to the mother first then to the toddler. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. Ignoring the crying and screaming may be the second step. The nurse should encourage the mother to hold the toddler because it will likely help the situation. The last resort is to bring in assistance so the procedure can be completed quickly.
A school-age child reveals to the nurse that his father has been abusing him. What constitutes a breach of the child's right to confidentiality? 1. Telling the child you're required by law to report the abuse 2. Informing the child's attending physician about the conversation 3. Telling the child in the next room, who also suffered abuse, so the two children can talk to each other 4. Informing local authorities and reporting the case
3. Telling the child in the next room, who also suffered abuse, so the two children can talk to each other RATIONALE: Children have a right to privacy and confidentiality when it comes to their medical condition, treatment plans, and even the fact that they are hospitalized. Therefore, telling another child about the abuse (even if they have that in common) is a breach of confidentiality. A nurse is required by law to report suspected child abuse to the proper local authorities. The attending physician is part of the health care team and needs to be informed about the suspected abuse. These actions don't breach the child's right to confidentiality.
A physician orders an antibiotic for a child, age 6, who has an upper respiratory tract infection. To avoid tooth discoloration, the nurse expects the physician to avoid prescribing which drug? 1. Penicillin 2. Erythromycin 3. Tetracycline 4. Amoxicillin
3. Tetracycline RATIONALE: Tetracycline should be avoided in children younger than age 8 because it may cause enamel hypoplasia and permanent yellowish gray to brownish tooth discoloration. Penicillin, erythromycin, and amoxicillin don't discolor the teeth.
For a child with tracheobronchitis, the nurse formulates a nursing diagnosis of Ineffective airway clearance related to thick secretions. After implementing interventions, the nurse expects which client outcome? 1. The child exhibits a respiratory rate of 44 breaths/minute. 2. The child exhibits an arterial oxygen saturation of 85%. 3. The child exhibits clear breath sounds. 4. The child exhibits increased anxiety.
3. The child exhibits clear breath sounds. RATIONALE: The nurse should expect clear breath sounds because this outcome indicates an improved respiratory status and airway clearance. A respiratory rate of 44 breaths/minute is high and indicates a respiratory problem. An arterial oxygen saturation of 85% is abnormally low. Decreased, not increased, anxiety would indicate effective airway clearance.
A 10-year-old child must undergo a surgical procedure. Does the nurse need to obtain consent from the child? 1. The child doesn't need to know about the procedure because he is a minor. 2. The child must sign the form giving written informed consent. 3. The child must be informed of the procedure and concur with his mother, who is giving written consent. 4. The child only needs to know if the procedure is part of a research protocol.
3. The child must be informed of the procedure and concur with his mother, who is giving written consent. RATIONALE: Assent, not consent, must be obtained from any child who is in the concrete operations thought stage of development (usually a child older than age 7). Assent involves knowledge of the procedure and agreement with the person authorized to give written informed consent. A child should always be notified of the treatment plan but he is too young to authorize consent. Careful ethical consideration should be given when using any person younger than age 18 in a research protocol.
During a vaginal exam of a client in labor, the nurse palpates the fetus' larger, diamond shaped fontanelle toward the anterior portion of the clients pelvis. Which of the following statements best describes this situation? 1. The client can expect a brief and intense labor, which potential for lacerations. 2. The client is at risk for uterine rupture and needs constant monitoring 3. The client may need interventions to ease back pain and change fetal position 4. The fetus will be delivered using forceps or vacuum extractor
3. The client may need interventions to ease back pain and change fetal position The fetal position is occiput posterior, a position that commonly produces intense back pain during labor. Most of the time, the fetus rotates during labor to occiput anterior position. Positioning the client on her side can facilitate this rotation. An occiput posterior position would most likely result in prolonged labor POSTERIOR - PROLONGED. occiput posterior alone doesnt create a risk of uterine rupture. The fetus wont be delivered with forceps / vacuum only if its presenting part DOESNT rotate and descend spontaneously
39. The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort during the procedure.
3. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.
A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next? 1. No further action is necessary. 2. The nurse should notify the physician of the error. 3. The nurse should follow facility procedures for reporting an error. 4. The nurse should document a medication error in the client's chart.
3. The nurse should follow facility procedures for reporting an error. RATIONALE: Although no harm came to the child, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error because it allows the facility to adequately assess the causes of medication errors, and isn't meant to place blame on any one person. The nurse in this instance doesn't need to notify the physician because there was no harm to the child. Also, the nurse shouldn't document that an error took place in the child's chart; doing so may place her at risk in the event of a lawsuit.
A 7-year-old child is admitted with epiglottiditis. Which is the most likely finding on a lateral neck X-ray in a child with this condition? 1. Supraglottic narrowing 2. Steeple sign 3. Thickened mass 4. Subglottic narrowing
3. Thickened mass RATIONALE: X-ray assessment of the lateral neck helps diagnose common respiratory emergencies in children. The lateral neck X-ray of a child with epiglottiditis shows a thickened mass. The steeple sign is found in a child with viral croup syndrome. Subglottic narrowing with membranous tracheal exudate is found in bacterial tracheitis. Supraglottic narrowing isn't a diagnostic indicator.
A mother tells the nurse that her 22-month-old child says no to everything. When scolded, the toddler gets angry and starts crying loudly but then immediately wants to be held. What is the best interpretation of this behavior? 1. The toddler isn't coping with stress effectively. 2. The toddler's need for affection isn't being met. 3. This behavior is normal in a 2-year-old child. 4. This behavior suggests the need for counseling.
3. This behavior is normal in a 2-year-old child. RATIONALE: Toddlers are confronted with the conflict of achieving autonomy yet relinquishing their much-enjoyed dependence on — and affection of — others. Therefore, their negativism is a necessary assertion of self-control and should be considered a normal behavior. Nothing about this behavior indicates that the child is under stress, isn't receiving sufficient affection, or requires counseling.
A physician orders corticosteroids for a child with nephrotic syndrome. What is the primary purpose of administering corticosteroids to this child? 1. To increase blood pressure 2. To reduce inflammation 3. To decrease proteinuria 4. To prevent infection
3. To decrease proteinuria RATIONALE: The primary purpose of administering corticosteroids to a child with nephrotic syndrome is to decrease proteinuria. Corticosteroids have no effect on blood pressure. Although they help reduce inflammation, this isn't the reason for their use in clients with nephrotic syndrome. Corticosteroids may predispose a client to, rather than prevent infection.
When developing a care plan for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's oral stage of psychosexual development? 1. Initiative versus guilt 2. Autonomy versus shame and doubt 3. Trust versus mistrust 4. Industry versus inferiority
3. Trust versus mistrust RATIONALE: Freud defined the first 2 years of life as the oral stage and suggested that the mouth is the primary source of satisfaction for the developing child. Erikson posited that infancy (from birth to age 12 months) is the stage of trust versus mistrust, during which the infant learns to deal with the environment through the emergence of trustfulness or mistrust. Initiative versus guilt corresponds to Freud's phallic stage. Autonomy versus shame and doubt corresponds to Freud's anal/sensory stage. Industry versus inferiority corresponds to Freud's latency period.
Parents of a 6-year-old tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure? 1. Complex partial 2. Myoclonic 3. Typical absence 4. Tonic
3. Typical absence RATIONALE: This child is probably having typical absence seizures. Typical absence seizures have an onset between ages 3 and 12. This type of seizure is exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized by staring and a 3-cycle/second spike and waveform on an EEG. The attack lasts from 10 to 30 seconds and may occur as frequently as 50 to 100 times a day. No postictal or confused state follows the attack. A complex partial seizure causes a brief impairment of consciousness. A myoclonic seizure occurs in older children and is exhibited by lightning jerks without loss of consciousness. An abrupt increase in muscle tone, loss of consciousness, and marked autonomic signs and symptoms characterize the tonic seizure.
A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? 1. Up to 10 2. Up to 15 3. Up to 20 4. Up to 32
3. Up to 20 RATIONALE: A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13.
The nurse receives an order to start an infusion for a client whos hemorrhaging due to a placenta previa. What supplies will be needed? 1. Y tubing, normal saline solution, and 20G cathether 2. Ytubing, lactated Ringers solution and 18G cath 3. Y tubing, normal saline, 18G cath 4. Y tubing, lactated RIngers, 20G cath
3. Y tubing, normal saline, 18G cath blood transfusions require Y tubing Normal Saline solution to mix with the blood product and an 18G cath to avoid lysing breaking the RBCs. A 20G cath lumen isnt large enough for a blood transfusion. Lactated RIngers solutions isnt the IV solution of choice for blood transfusions
A nurse should determine a child's body surface area by using: 1. weight. 2. height. 3. a nomogram. 4. the difference between weight and height.
3. a nomogram. RATIONALE: The method for determining body surface area is a three-column chart called a nomogram. The nurse marks the child's height in the first column and weight in the third column, then draws a line between the two marks. The point at which the line intersects the vertical scale in the second column indicates the estimated body surface area of the child in square meters. Using height or weight alone isn't sufficient, and the difference between weight and height isn't a measurement of body surface area.
A mother and infant are admitted to the emergency department following a motor vehicle crash. The infant is unresponsive to verbal and tactile stimuli, his pupils are dilated, and a nurse observes lacerations on his head, neck, and upper torso. The infant's mother is experiencing respiratory distress and is being treated in another room in the emergency department. The nurse learns that the parents are divorced and have joint custody of the infant. The father arrives in the emergency department. The nurse should: 1. contact social services to establish contact with the next of kin and obtain consent to treat the mother and infant. 2. ask the infant's father to sign consents for emergency treatment of the mother and infant. 3. ask the infant's father to sign consent for emergency treatment of the infant. 4. contact social services to establish contact with the court to obtain consent to treat the infant.
3. ask the infant's father to sign consent for emergency treatment of the infant. RATIONALE: The father may give consent for treatment of the infant, but he may not give consent to treat the mother (his former wife). The mother's next of kin should be contacted for consent. Because the father may give consent for the infant to be treated, it isn't necessary to contact the court at this time.
When planning care for a 7-year-old boy with Down syndrome, the nurse should: 1. plan interventions at the developmental level of a 7-year-old because that is the child's age. 2. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays. 3. assess the child's current developmental level and plan care accordingly. 4. direct all teaching to the parents because the child can't understand.
3. assess the child's current developmental level and plan care accordingly. RATIONALE: Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. Directing all teaching to parents isn't appropriate because a child with Down syndrome is capable of learning, especially one with mild limitations.
A nurse is giving instructions to parents of a school-age child diagnosed with sickle cell anemia. The instructions should include: 1. applying cold to affected areas to reduce the child's discomfort. 2. restricting the child's fluids during crisis situations. 3. avoiding areas of low oxygen concentration such as high altitudes. 4. encouraging the child to exercise to reduce the likelihood of crisis.
3. avoiding areas of low oxygen concentration such as high altitudes. RATIONALE: The child should avoid areas of low oxygen, such as high altitudes, because they may precipitate sickle cell crisis. Applying warm compresses will reduce discomfort to the affected area; cold compresses, however, may add to discomfort by increasing sickling and impairing circulation. The child should be encouraged to drink fluids to rehydrate cells. Strenuous exercise may induce, not reduce, sickle cell crisis.
A child, age 5, has acute lymphocytic leukemia (ALL) and is receiving induction chemotherapy consisting of vincristine (Oncovin), asparaginase (L-asparaginase [Elspar]), and prednisone (Deltasone). When teaching the parents about the adverse effects of this regimen, the nurse should stress the importance of promptly reporting: 1. hair loss. 2. moon face. 3. blindness. 4. bone pain.
3. blindness. RATIONALE: Neurotoxicity, the primary adverse effect of vincristine, may manifest as blindness that the parents must report promptly. Neurotoxicity may also cause peripheral neuropathy. Hair loss and moon face are expected adverse effects of this chemotherapy regimen and will resolve once therapy ends. Bone pain is common in clients with ALL and results from invasion of the periosteum by leukemic cells.
A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: 1. reintroduce the tube and attach it to water seal drainage. 2. call a physician and obtain a chest tray. 3. cover the opening with petroleum gauze. 4. clean the wound with povidone-iodine and apply a gauze dressing.
3. cover the opening with petroleum gauze. RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.
WHich finding might be seem in a neonate suspected of having an infection? 1. flushed cheeks 2. increased temp 3. decreased temp 4. increased activity level
3. decreased temp temp instability esp when it resutls in low temp in the neonate, may be a sign of infection. the neonate's color often changes with an infection process but generally becomes ashen or mottled the neonate w/ an infection will usually show a decrease in activity level or lethargy
A client has just given birth at 42 weeks gestation. When assessing the neontate, which phsycial finding is expected? 1. a sleepy, lethargic baby 2. lanugo covering body 3. desquamation of the epidermis 4. vernix caseosa covering the body
3. desquamation of the epidermis postdate fetuses lose the vernix caseosa and the epidermis may become desquamated these neonates are usually VERY alert lanugo is missing in the postdate neonate
While providing care for a hospitalized infant, a nurse is summoned to the phone. The caller requests information about the infant's condition. The nurse should: 1. update the caller in the interest of good public relations. 2. protect the infant's confidentiality by divulging no information to the caller. 3. determine the caller's identity before responding. 4. transfer the call to the infant's room.
3. determine the caller's identity before responding. RATIONALE: The nurse must identify the caller before giving information or refusing to give information. Client confidentiality is mandatory and isn't negated by the concept of public relations. The caller's identity and relationship to the infant may make it appropriate for the nurse to divulge information over the phone. The nurse doesn't need to transfer the call.
A 14-month-old child with acquired immunodeficiency syndrome (AIDS) is admitted to the facility with an infection. When developing a care plan, the nurse must keep in mind that AIDS in children commonly is associated with: 1. Kaposi's sarcoma. 2. congenital heart anomalies. 3. developmental delays. 4. Wiskott-Aldrich syndrome.
3. developmental delays. RATIONALE: Children with AIDS commonly exhibit developmental delays or regression. To plan developmentally appropriate care and establish realistic goals, the nurse must obtain information about the child's developmental status. Unlike adults with AIDS, children with this disease rarely develop Kaposi's sarcoma. AIDS isn't associated with congenital heart anomalies. Clinical manifestations of Wiskott-Aldrich syndrome, an X-linked recessive disorder characterized by immunodeficiency, resemble those of AIDS; however, the two syndromes aren't related.
A nurse observes a 10-month-old infant chewing on the security alarm attached to his identification bracelet. The nurse should: 1. remove the security device because it's a choking hazard. 2. instruct the infant to stop chewing on the device. 3. distract the infant with a more appropriate toy. 4. instruct the infant's parent regarding the safety hazard.
3. distract the infant with a more appropriate toy. RATIONALE: Distraction with an appropriate chewing toy provides safety and is developmentally supportive. Removing the security device isn't appropriate; it must remain attached to the infant. Telling an infant not to chew on the security device isn't appropriate because chewing is typical behavior at the age of 10 months. Instructing the infant's parents about the safety hazard isn't the best response; doing so won't eliminate the immediate hazard and doesn't refocus the infant's attention.
A 2-year-old child is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and alert. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should: 1. question the mother about the child's allergies. 2. initiate standard precautions. 3. evaluate the child's neurologic status. 4. examine the child's throat and ears.
3. evaluate the child's neurologic status. RATIONALE: Petechiae across the child's chest, abdomen, and back are signs of meningitis. The priority is to evaluate neurologic status. Petechiae aren't allergic reactions, so the nurse shouldn't ask about allergies. Standard precautions should be used when there is risk of contacting body fluids. Contact precautions should be instituted for the client diagnosed with meningitis. Throat and ear examinations wouldn't be helpful in confirming a diagnosis of meningitis.
A nurse is teaching childcare classes for adolescent mothers. To enhance the adolescents' understanding of infant safety in relation to the infant's perspective, the nurse should: 1. instruct the adolescents to discuss infant safety with their pediatricians. 2. present a video about pregnancy prevention. 3. have the adolescents crawl around on the floor to look for potential hazards. 4. lecture the adolescents about poison control.
3. have the adolescents crawl around on the floor to look for potential hazards. RATIONALE: Crawling on the floor is a participative activity that can help promote understanding of infant safety in relation to the infant's perspective. The nurse doesn't need to instruct the adolescents to discuss infant safety with their pediatricians because she can provide such information in the class environment. Presenting a lecture or video doesn't directly focus on the infant's perspective on safety.
The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children: 1. have smaller body surface areas than adults. 2. breathe at a slower rate than adults. 3. have thinner skin than adults. 4. have a low risk of developing rapid dehydration.
3. have thinner skin than adults. RATIONALE: Children are more susceptible to the effects of chemical and biological attacks because they have thinner skin than adults, increasing their risk of absorbing a chemical. They also have a larger, not smaller, body surface area in relation to their weight than do adults, which increases the chance of chemical absorption. Children breathe at a faster, not slower, rate than adults, allowing them to inhale greater amounts of a toxic agent. Additionally, some chemical agents are heavier than air and accumulate close to the ground, which is closer to a child's breathing zone than an adult's. Because they have less fluid reserve than adults, children are at greater risk of developing rapid dehydration from agents that cause vomiting or diarrhea.
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can: 1. prepare the child by positive self-talk. 2. establish a time limit to get ready for the procedure. 3. hold and rock him and give him a security object. 4. count and sing with the child.
3. hold and rock him and give him a security object. RATIONALE: The child with Down syndrome may have difficulty coping with painful procedures and may regress during his illness. Holding, rocking, and giving the child a security object is helpful because it may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; however, the success of these tactics depends on the child.
A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother: 1. how long the child has been like this. 2. if the child is able to walk without holding onto furniture. 3. how the child's condition today differs from his normal condition. 4. if the child always drools.
3. how the child's condition today differs from his normal condition. RATIONALE: The nurse should ask how the child's condition differs from his normal condition in order to identify the chief complaint. Asking how long the child has been like this may be interpreted poorly by the caregiver. The nurse shouldn't ask if the child can walk without holding onto furniture because focusing on what the child can do — not on what he can't do — preserves the family's self-esteem. Focusing on negative aspects of the child's behavior, such as constant drooling, is inappropriate.
A child with a full-thickness burn is scheduled for debridement using hydrotherapy. Before hydrotherapy begins, the nurse should: 1. administer fluids as ordered. 2. administer antibiotics as ordered. 3. implement pain control measures. 4. provide nutritional supplements.
3. implement pain control measures. RATIONALE: Because hydrotherapy is painful, the nurse should implement pain control measures before this treatment begins. Fluids and nutritional supplements can be given at any time and aren't required specifically before hydrotherapy. Antibiotics should be administered according to a specified schedule without regard to any treatment.
The nurse is administering the Denver Developmental Screening Test to a 6-month-old infant during a well-baby checkup. She notes that the child is unable to use a pincer grasp. The nurse notes that this finding: 1. suggests the infant needs a neurologic evaluation. 2. indicates the need for further developmental testing. 3. is a normal finding in a 6-month-old infant. 4. indicates the infant is ahead in developmental milestones.
3. is a normal finding in a 6-month-old infant. RATIONALE: The Denver Developmental Screening Test evaluates the developmental level of social, motor, and language skills in children ages 1 month to 6 years. An infant doesn't develop the ability to use a pincer grasp until about 9 months, so the lack of such a grasp in a 6-month-old infant is a normal finding. A neurologic evaluation or more developmental testing isn't indicated.
Parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age: 1. still depends on the parents. 2. rebels against scheduled activities. 3. is highly sensitive to criticism. 4. loves to tattle.
3. is highly sensitive to criticism. RATIONALE: A nurse should explain that a 6-year-old child has a precarious sense of self that can cause overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and actually love the routine of a schedule. Tattling is more common at age 4 or 5; by age 6, the child wants to make friends and be a friend.
Family members and friends stage an intervention for an alcoholic adolescent. The intervention is successful when the adolescent: 1. breaks down and cries. 2. says, "I'm sorry. I'll never drink again." 3. is motivated to enter an alcohol rehabilitation program. 4. is willing to talk with his friends.
3. is motivated to enter an alcohol rehabilitation program. RATIONALE: Willingness to enter a rehabilitation program indicates that the adolescent is motivated to change. An intervention is an emotionally charged meeting; crying may be an indication of manipulation, rather than a sign that the intervention has succeeded. Relapses are common among alcoholics who simply stop drinking; success in overcoming alcoholism is more likely when a structured program is part of the rehabilitation process. Talking with friends doesn't indicate a successful intervention.
3 day old neonate needs phototherapy for hyperbilirubinemia. nursery care of a neonate getting phototherapy would include which nursing intervention? 1. tube feedings 2. feeding the neonate under phototheraphy lights 3. mask over the eyes to prevent retinal damage 4. temp monitored every 6 hours during phototherapy
3. mask the neonate's eyes must be covered with eye patches to prevent damage the mouth of the neonate doesnt need to be covered the neonate can be removed from the lights and held for feeding the neonates temp should be monitored at least every 2-4 hours due to risk of hyperthermia w/ phototherpahy
A child, age 5, is to have potassium added to his I.V. fluid. Before initiating this therapy, the nurse first should: 1. assess the child's apical pulse rate. 2. measure the blood pressure. 3. monitor fluid intake and output. 4. assess respiratory rate and depth.
3. monitor fluid intake and output. RATIONALE: The nurse should first monitor fluid intake and output because potassium shouldn't be added to the I.V. fluid until the child's kidney function is shown to be adequate, as indicated by balanced fluid intake and output and certain diagnostic test results. Assessing the child's apical pulse rate, measuring blood pressure, and assessing respiratory rate and depth aren't related to potassium administration.
Which of the following conditions is common in pregnant clients in the 2nd trimester of preg? 1. mastitis 2. metabolic alkalosis 3. physiologic anemia 4. respiratory acidosis
3. physiologic anemia Hgb and Hct values DECREASE during preg as the INCREASE in plasma volume exceeds the increase in RBC production. Alterations in acid-base balance during pregnancy result in a state of resp. alkalosis, compensated by mild metabolic acidosis. Mastitis is an infection in the breast characterized by a swollen tender breast and flu like Sx. this condition is most freq. seen in breast feeding clients.
A 3-month-old infant just had a cleft lip and palette repair. To prevent trauma to the operative site, the nurse should: 1. give the infant a pacifier to help soothe him. 2. lie the infant in the prone position. 3. place the infant's arms in soft elbow restraints. 4. avoid touching the suture line, even to clean.
3. place the infant's arms in soft elbow restraints. RATIONALE: Soft restraints from the upper arm to the wrist are appropriate because they prevent the infant from touching his lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers, suction catheters, and small spoons shouldn't be placed in an infant's mouth after cleft palette repair. An infant in a prone position may rub his face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can widen the scar.
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to: 1. place ice packs on the client's painful joints. 2. administer antibiotics. 3. provide oral and I.V. fluids. 4. administer folic acid supplements.
3. provide oral and I.V. fluids. RATIONALE: Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but they aren't a priority during sickle cell crisis.
Which of the following complications can be potentially life threatening and can occur in a client receiving a tocolytic agent? 1. diabetic ketoacidosis 2. hyperemesis gravidarum 3. pulmonary edema 4. sickle cell anemia
3. pulmonary edema Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Clients who dont have diabetes dont need to be observed for diabetic ketoacidosis. Hyperemesis gravidium doesnt result from tocolytic use. Sickle cell anemia is an inherited genetic condition and doesnt develop spontaneously
A nurse is caring for a 19-month-old infant with dehydration and weight loss. The infant's mother states that her son doesn't like to eat and that she hates to make him eat. The nurse should: 1. contact the social worker on duty and give her information about the situation. 2. contact the physician to have the child put in isolation. 3. request that a dietitian talk with the parent about infants and nutrition. 4. contact the local police department to report suspected child abuse.
3. request that a dietitian talk with the parent about infants and nutrition. RATIONALE: The infant's mother needs assistance in maintaining her child's diet. Requesting that a dietitian speak with the mother about the child's diet is within the nurse's scope of practice. The nurse shouldn't call the local police or the social worker on duty because there is no evidence of child abuse or neglect. Many infants are picky eaters and choose not to eat or drink. The nurse doesn't need to call the physician to have the infant put in isolation. Isolation isn't indicated for dehydration.
A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to: 1. teach children to cover mouths and noses when they sneeze. 2. have their children immunized against impetigo. 3. teach children the importance of proper hand washing. 4. isolate the child with impetigo from other members of the family.
3. teach children the importance of proper hand washing. RATIONALE: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing won't prevent its spread. Currently, there is no vaccine to prevent a child from contracting impetigo. Isolating the child with impetigo is unnecessary.
For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate (Amoxil) to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin (Mycostatin) to be applied to the perineum four times daily. The nurse should focus her assessment on: 1. the infant's heart and respiratory rate. 2. the infant's fontanels. 3. the inside of the infant's mouth. 4. the infant's height and weight.
3. the inside of the infant's mouth. RATIONALE: The nurse should pay close attention to the inside of the infant's mouth for white patches. Signs of thrush, these patches are common in children with C. albicans infections and should be reported to the physician. Although the other assessments should be performed as a part of an infant evaluation, they aren't the nurse's primary focus in this situation.
A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? 1. apply alcohol to the site 2. Change the diaper as needed 3. keep the neonate in supine position 4. apply petroleum gauze to the site for 24 hours
4. Petroleum gauze is applied to the site for the 1st 24 hours to prevent the skin edges from sticking to the diaper neonates are initially kept in the prone position diapers are changed more freq to insepct the site alcohola is CONTRAINDICATED
The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care? 1. Use of a fracture bedpan. 2. Checks for redness over the ischial tuberosity. 3. Elevation of the head of bed no more than 25 degrees. 4. Personal hygiene with a complete bed bath.
4. The client with a femoral fracture in balanced suspension traction should not be given a complete bed bath. Rather, the client is encouraged to participate in self-care and movement in bed, such as with a trapeze triangle. Use of a fracture bedpan is appropriate. A fracture bedpan is lower, and it is easier for the client to move on and off the bedpan without altering the line of traction. Checking for areas of redness or pressure over all areas in contact with the traction or bed, including the ischial tuberosity, is important to prevent possible skin breakdown. The client should be positioned so that the feet do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? 1. Crackles. 2. Jaundice. 3. Generalized edema. 4. Dark, scanty urine.
4. The client with compartment syndrome may release myoglobin from damaged muscle cells into the circulation. This becomes trapped in the renal tubules, resulting in dark, scanty urine, possibly leading to acute renal failure. Crackles may suggest respiratory complications; jaundice suggests liver failure; and generalized edema may suggest heart failure. However, these are not associated with compartment syndrome.
An 11-year-old child is diagnosed with scoliosis and scheduled for brace application. The mother asks the nurse how long her child will have to wear the brace. How should the nurse respond? 1. "About 6 to 8 weeks." 2. "About 6 months." 3. "About 1 to 2 years." 4. "About 3 to 5 years."
4. "About 3 to 5 years." RATIONALE: Most children with scoliosis must wear a brace until the spine matures — typically between ages 14 and 16. Therefore, this 11-year-old child will need to wear the brace for 3 to 5 years.
A mother complains to the nurse that her 4-year-old son often "lies." What is the nurse's best response? 1. "Let the child know that he'll be punished for lying." 2. "Ask him why he isn't telling the truth." 3. "It's probably due to his vivid imagination and creativity." 4. "Acknowledge him by saying, 'That's a pretend story.'"
4. "Acknowledge him by saying, 'That's a pretend story.'" RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Although imagination and creativity need to be acknowledged by the mother, the nurse must respond to the mother's concern with appropriate interventions, not opinion on why the behavior is occurring.
Parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate? 1. "Children of that age view death as temporary and reversible, which makes it hard to explain." 2. "Children of that age typically fantasize about what dying will be like, which is much better than knowing the truth." 3. "At this developmental stage, children are afraid of death, so it's best not to discuss it with them." 4. "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."
4. "At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it." RATIONALE: By age 9 or 10, most children have an adult concept of death. Therefore, caregivers should discuss death with them in terms consistent with their developmental stage. In addition, school-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. While school-age children may fantasize about the unknown aspects of death, these fantasies may actually increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.
The mother of a 16-year-old girl calls the emergency department, suspecting her daughter's abdominal pain may be appendicitis. In addition to pain, her daughter has a temperature of 100° F (37.7° C) and has vomited twice. What should the nurse tell the mother? 1. "Give your daughter a laxative to rule out the possibility that constipation is causing the pain." 2. "Gently press on the lower left quadrant of your daughter's abdomen to test for rebound tenderness." 3. "It's most likely the flu because your daughter is too young to have appendicitis." 4. "Bring your daughter into the emergency department immediately before her appendix has a chance to rupture."
4. "Bring your daughter into the emergency department immediately before her appendix has a chance to rupture." RATIONALE: Abdominal pain, low-grade fever, and vomiting are cardinal signs of appendicitis. The nurse should instruct the mother to take the girl to the emergency department. Telling the mother to give the girl a laxative is inappropriate because if appendicitis is the cause of the pain the appendix may rupture as a result of the drug. Appendicitis can occur at any age. Rebound tenderness is a symptom of appendicitis, but this finding would be found in the right lower quadrant, not the left.
A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request? 1. "What would you like to know?" 2. "Let's discuss what your friends are doing to keep from getting pregnant." 3. "Can you tell me if you've told your parents you're having sex?" 4. "Can you tell me about the precautions you're taking now?"
4. "Can you tell me about the precautions you're taking now?" RATIONALE: An attitude that requests only the information the girl is willing to give is nonthreatening and nonjudgmental. This may enhance the girl's willingness to talk about her experiences, thus enabling the nurse to better assess her needs. Asking what the girl would like to know assumes the girl knows what information she needs. The precautions her friends are taking are irrelevant at this time. Referencing the girl's parents may make her defensive and fearful.
A 10-year-old girl visits the clinic for a checkup before entering school. The child's mother questions the nurse about what to expect of her daughter's growth and development at this stage. Which response is appropriate? 1. "Her physical development will be rapid at this stage, and rapid development will continue from now on." 2. "She'll become more independent and won't require parental supervision." 3. "Don't anticipate any changes at this stage in her growth and development." 4. "Friends will be very important to her, and she'll develop an interest in the opposite sex."
4. "Friends will be very important to her, and she'll develop an interest in the opposite sex." RATIONALE: At age 10, friends become very important. Also, children usually begin having an interest in the opposite sex around this age, although they aren't always willing to admit it. Her physical development towards maturity continues, but it isn't as rapid at this stage as in previous years. Although independence increases at this stage, children continue to need parental supervision. Growth and development slow down but gradual changes continue to occur.
A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The nurse asks the parents if the client has an advance directive. Which response by the parents leads the nurse to believe that the parents don't understand the severity of the client's medical condition? 1. "He has pneumonia; I shouldn't have let him go to that party last week." 2. "This is the third time he's had pneumonia in the past 6 months. I'm afraid he needs a feeding tube." 3. "Yes, he has an advance directive." 4. "He is only 17. He doesn't need an advance directive."
4. "He is only 17. He doesn't need an advance directive." RATIONALE: The parents stating that their son is too young for an advanced directive suggests that the parents don't fully understand the seriousness of their son's medical condition. Advance directives can be used for any client who has an irreversible condition. Stating that they shouldn't have allowed their son to go to a party shows a lack of knowledge about acquiring aspiration pneumonia. Being concerned about the need for a feeding tube and having an advance directive show an understanding of their son's condition.
A 4-year-old girl has a urinary tract infection (UTI). Which statement by the mother demonstrates understanding of preventing future UTIs? 1. "I should help my child learn to wipe her bottom from back to front." 2. "When she starts urinating frequently, I should call the physician to request antibiotics." 3. "I will let her take a warm bath for 15 minutes each day." 4. "I shouldn't let my daughter take bubble baths."
4. "I shouldn't let my daughter take bubble baths." RATIONALE: Saying that the child shouldn't take bubble baths demonstrates effective teaching because oils in the bubble bath preparation may irritate the urethra, contributing to UTIs. Girls and women should wipe the perineum from front to back, not back to front, to avoid contaminating the urinary tract with fecal bacteria. Although antibiotics are used to treat UTIs, they aren't given prophylactically. No evidence suggests that warm baths help prevent UTIs.
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the father indicates the need for further teaching? 1. "I hope this cast will cure his feet in the next several weeks." 2. "I know I will have to be careful when changing his diapers." 3. "We will have to be careful how we hold our baby." 4. "Immunizations will have to be delayed until the casts come off."
4. "Immunizations will have to be delayed until the casts come off." RATIONALE: The father's statement about delaying immunizations indicates the need for further teaching. Immunizations can be administered in the thighs because the casts cover only the lower legs and feet. The other responses are correct statements, indicating effective teaching.
A toddler is in the hospital. The parents tell the nurse they're concerned about the seriousness of the child's illness. Which response to the parents is most appropriate? 1. "Please try not to worry. Your child will be fine." 2. "If you look around, you'll see other children who are much sicker." 3. "What seems to concern you about your child being hospitalized?" 4. "It must be difficult for you when your child is ill and hospitalized."
4. "It must be difficult for you when your child is ill and hospitalized." RATIONALE: Expressing concern is the most appropriate response because it acknowledges the parents' feelings. False reassurance, such as telling parents not to worry, isn't helpful because it doesn't acknowledge their feelings. Encouraging parents to look at how ill other children are also isn't helpful because the focus of the parents is on their own child. Asking what the concern is merely reinforces the parents' concern without addressing it.
During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction? 1. "Offer dry toast and crackers." 2. "Withhold all food and fluids." 3. "Ignore your child's lack of food intake." 4. "Let your child eat any food he wants."
4. "Let your child eat any food he wants." RATIONALE: The nurse should instruct the parents to let the child eat any food he wants because any form of intake is better than none. Dry crackers or toast would be appropriate for a child experiencing nausea. Withholding all foods and fluids or ignoring lack of food intake would be inappropriate.
A nurse in a clinic finds the mother of a 15-month-old child in tears. The mother states that her child doesn't love her because the child says "no" to everything. Which response is appropriate? 1. "Have you punished your child for saying 'no' to you?" 2. "This is normal at this age; it's best to ignore the behavior." 3. "Explain to your child that saying 'no' all of the time is inappropriate behavior." 4. "Saying 'no' is part of toddler development and is normal at this age."
4. "Saying 'no' is part of toddler development and is normal at this age." RATIONALE: Telling the mother that saying "no" is normal for a 15-month-old child is an appropriate response. The child's behavior doesn't mean that the child doesn't love the mother. It means the child is attempting to exert independence. Punishing the child isn't appropriate because this is a normal stage of development. Saying that it's best to ignore the behavior is also inappropriate because the child needs to learn about limits. Explaining to the child that his behavior is inappropriate isn't an age-appropriate response for this child.
During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal? 1. "The baby's stools are yellow and semiformed." 2. "The baby's stools are dark green and sticky." 3. "The baby's stools are green and watery." 4. "The baby's stools are bright yellow and soft."
4. "The baby's stools are bright yellow and soft." RATIONALE: Breast-fed infants typically have soft, bright yellow or light green stools with no offensive odor. Formula-fed infants typically have pale yellow, semiformed stools with a strong odor. A neonate's first stools typically are dark green to black, sticky, and odorless (representing meconium, usually present for the first 3 days). By the fourth day, yellowish green transitional stools appear. Green, watery stools indicate diarrhea.
The parents of a 9-year-old child who is scheduled to have surgery ask the nurse not to tell him about the surgery until he's taken to the operating room. Which response best demonstrates the nurse's role in supporting the child's rights? 1. "I agree that the child shouldn't be told about the surgery until it's absolutely necessary to avoid unnecessary stress." 2. "The child should be aware of the impending surgery so he can give informed consent." 3. "I must inform the child because the hospital requires that he be made aware of the surgery." 4. "The child should be aware of the impending surgery so he can develop coping strategies and his questions can be answered."
4. "The child should be aware of the impending surgery so he can develop coping strategies and his questions can be answered." RATIONALE: Advance awareness of the surgery and its significance offers a school-age child time to develop coping strategies and formulate questions. Failure to inform the child about the surgery may result in fear or mistrust of health care workers or the health care system. A school-age child can't give operative consent. Although hospital requirements may require the nurse to inform a child of impending surgery, this response doesn't best reflect the nurse's promotion of the child's rights.
A nurse is providing injury-prevention education to the parents of a school-age child. The parents admit that they keep a gun in their home. Which of the nurse's statements is most appropriate? 1. "The gun should be kept in a discreet location out of your child's sight." 2. "Your child should attend a community gun-safety program." 3. "Remind your child that only a parent may touch the gun." 4. "The gun should be stored in a locked cabinet."
4. "The gun should be stored in a locked cabinet." RATIONALE: The nurse should instruct the parents to keep the gun in a locked cabinet. Keeping the gun out of the child's sight isn't sufficient; the child might be able to locate the gun. It's inappropriate to refer a school-age child to a gun-safety program. The parents shouldn't keep the gun on hand with the understanding that the child won't touch it.
A nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is appropriate? 1. "Don't worry. It won't hurt." 2. "The test usually takes an hour." 3. "You must sleep the whole time that the test is being done." 4. "The special medicine will feel warm when it's put in the tubing."
4. "The special medicine will feel warm when it's put in the tubing." RATIONALE: To prepare a 4-year-old child without increasing anxiety, the nurse should provide concrete information in small amounts about nonthreatening aspects of the procedure. Therefore, saying the special medicine will feel warm is most appropriate. Saying that it won't hurt may prevent the child from trusting the nurse in the future. Explaining the time needed for the procedure wouldn't provide sufficient information. Stating that the child will need to sleep isn't true and could provoke anxiety.
When teaching parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction? 1. "Reduce your child's caloric intake to decrease cardiac demand." 2. "Relax discipline and limit-setting to prevent crying." 3. "Make sure your child avoids contact with small children to reduce overstimulation." 4. "Try to maintain your child's usual lifestyle to promote normal development."
4. "Try to maintain your child's usual lifestyle to promote normal development." RATIONALE: The nurse should encourage the parents of a child with a congenital heart defect to treat the child normally and allow self-limited activity. Telling the parents to reduce the child's caloric intake isn't appropriate because doing so wouldn't necessarily reduce cardiac demand. Telling the parents to alter disciplinary patterns and deliberately prevent crying or interactions with other children could foster maladaptive behaviors. Contact with peers promotes normal growth and development.
A nurse is teaching parents how to select appropriate toys for their 10-month-old infant. Which statement by the parents indicates effective teaching? 1. "We'll get a mobile to place over the baby's crib." 2. "We'll get a rattle for the baby to play with." 3. "We'll get the baby some brightly colored blocks." 4. "We'll get the baby a push toy."
4. "We'll get the baby a push toy." RATIONALE: Effective teaching is demonstrated if the parents say they'll get the baby a push toy because at age 10 months, a push toy promotes development of an infant's gross and fine motor skills and aids cognitive development. A mobile provides appropriate visual stimulation for an infant up to age 4 months; after this age, a mobile may pose a danger to an infant. Rattles and brightly colored blocks promote gross and fine motor abilities in infants ages 4 to 8 months.
Parents report that their daughter, age 4, resists going to bed at night. After instruction by the nurse, which statement by the parents indicates effective teaching? 1. "We'll let her fall asleep in our room, then move her to her own room." 2. "We'll lock her in her room if she gets up more than once." 3. "We'll play running games with her before bedtime to tire her out, and then she'll fall asleep easily." 4. "We'll read her a story and let her play quietly in her bed until she falls asleep."
4. "We'll read her a story and let her play quietly in her bed until she falls asleep." RATIONALE: The parents stating that they'll read the child a story and let her play quietly demonstrates effective teaching because spending time with the parents and playing quietly are positive bedtime routines that provide security and prepare a child for sleep. Saying that they will let their daughter fall asleep in their room reflects ineffective teaching because the child should sleep in her own bed. Locking the door is frightening and may cause insecurity. Active play before bedtime stimulates the child and increases the time needed to settle down for sleep; therefore, a statement about running games would demonstrate ineffective teaching.
A child, age 3, who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond? 1. "Make sure the child uses disposable plates and utensils." 2. "Use isopropyl alcohol to clean surfaces contaminated with the child's blood or body fluids." 3. "Don't let the child share toys with other children." 4. "Wear gloves when you're likely to come into contact with the child's blood or body fluids."
4. "Wear gloves when you're likely to come into contact with the child's blood or body fluids." RATIONALE: HIV is transmitted by blood and body fluids. Therefore, the nurse should respond by telling family members they should wear gloves when anticipating contact with the child's blood or body fluids. Standard household methods for cleaning dishes and utensils are adequate, so the child needn't use disposable plates and utensils. To disinfect HIV-contaminated surfaces, the nurse should instruct the foster parents to use a solution of 1 part bleach to 10 parts water. The child may share toys; any toys that become soiled with the child's blood or body fluids should be disinfected with the bleach solution.
A nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response? 1. "This is only a minor problem. Many other babies are born with worse defects." 2. "Don't worry. After surgical repair you'll hardly remember there was anything wrong with your baby." 3. "I'll ask the physician to explain to you how this defect occurs." 4. "You seem upset. Tell me about it."
4. "You seem upset. Tell me about it." RATIONALE: Asking the client to talk about her feelings is appropriate because by verbalizing the nurse acknowledges the client's feelings. By listening, the nurse acknowledges the client's feelings and can help the client understand them and begin to deal with them. Telling the client that there are babies with worse defects doesn't acknowledge — and may even belittle — her feelings. Providing a stock answer, such as "Don't worry," shows a lack of interest in the client's feelings. Offering to ask the physician also doesn't address the client's feelings.
A mother is playing with her infant, who's sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age should the nurse estimate the infant to be? 1. 4 months 2. 6 months 3. 8 months 4. 10 months
4. 10 months RATIONALE: The nurse would estimate that the infant is 10 months old because an infant this age can sit alone and understands object permanence, so he would look for the hidden toy. Between ages 4 and 6 months, children can't sit securely alone. At age 8 months, children can sit securely alone but don't understand the permanence of objects.
A nurse in a well-child clinic is assessing children for scoliosis. Which child is most at risk for scoliosis? 1. 8-year-old boy 2. Teenage boy 3. 6-year-old girl 4. 10-year-old girl
4. 10-year-old girl RATIONALE: The 10-year-old girl is most at risk because scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. The 8-year-old boy or a teenage boy may develop scoliosis but it's more common in females. A 6-year-old girl is typically too young to be diagnosed with scoliosis.
Which assessment should alert a nurse that a hospitalized 7-year-old child is at high risk for a severe asthma exacerbation? 1. Oxygen saturation of 95% 2. Mild work of breath 3. Intercostal or substernal retractions 4. A history of steroid-dependent asthma
4. A history of steroid-dependent asthma RATIONALE: The child's history of steroid-dependent asthma is a contributing factor to making him at high risk for a severe exacerbation. The nurse must treat the situation as a severe exacerbation regardless of the severity of the current episode. Decreased oxygen saturation, cyanosis, retractions, and increase (not mild) work of breathing are all assessments of an asthma exacerbation, not risk factors for it. These findings should be treated with oxygen, nebulized respiratory treatments, and steroids. However, if a significant history of high-risk factors is absent, the episode can be treated without hospitalization and followed up with the pediatrician.
A nurse is assessing a severely depressed adolescent. Which finding indicates a risk of suicide? 1. Excessive talking 2. Excessive sleepiness 3. A history of cocaine use 4. A preoccupation with death
4. A preoccupation with death RATIONALE: An adolescent who demonstrates a preoccupation with death (such as by talking frequently about death) should be considered at high risk for suicide. Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also occur in adolescents who aren't suicidal. Verbal and emotional withdrawal, not excessive talking, are signs of possible depression and suicide risk in an adolescent.
A nurse should question an order for intraosseous infusion of which agent? 1. Sodium bicarbonate 2. Dopamine (Intropin) 3. Calcium chloride 4. Acetaminophen (Tylenol)
4. Acetaminophen (Tylenol) RATIONALE: The nurse should question an order to administer acetaminophen by intraosseous infusion because the drug can only be administered orally or rectally. Any medication that can be administered via I.V. can be administered by intraosseous infusion. Therefore, sodium bicarbonate, dopamine, and calcium chloride can all be administered by way of intraosseous infusion.
When planning to administer medication to a 3-month-old infant, the nurse should keep which consideration in mind? 1. An infant's metabolic rate is slower than an adult's. 2. An infant's liver detoxifies drugs faster than an adult's. 3. An infant's systemic drug circulation is slower than an adult's. 4. An infant's kidneys excrete drugs more slowly than an adult's.
4. An infant's kidneys excrete drugs more slowly than an adult's. RATIONALE: Because an infant has immature kidney function, drugs excreted by the kidneys are excreted more slowly, significantly altering drug effects. An infant has a faster metabolic rate, slower drug detoxification, and faster systemic drug circulation than an adult.
When administering morphine to a school-age child, which sign or symptom should cause the nurse to be concerned? 1. Constipation 2. Nausea and vomiting 3. Pruritus 4. Anemia
4. Anemia RATIONALE: The nurse should be concerned about anemia because it isn't a typical adverse effect of morphine. This sign should be investigated if it's discovered during treatment. Constipation, nausea and vomiting, and pruritus are all treatable adverse effects of morphine and don't necessitate discontinuation of the medication.
Which assessment finding would be the most unlikely risk factor for RDS 1. second born of twins 2. neonate born at 34 weeks 3. neonate of diabetic mom 4. chronic maternal HTN
4. CHRONIC MATERNAL HTN unlikely factor bc chronic fetal stress tends to INCREASE LUNG MATURITY premature neonates < 35 weeks are associated with RDS Even with a mature lecithin to sphingomyelin ration, neonates of moms with diabetes still develop RDS 2nd born of twins may be prone to greater risk of asphyxia
Black wounds are treated with debridement. Which type of debridement is most selective and least damaging? 1. Debridement with scissors 2. Debridement with wet to dry dressings 3. Mechanical debridement 4. Chemical debridement
4. Chemical debridement; Chemical debridement is either done with enzyme agents or autolytic agents. Answer 1 is a type of sharp debridement. Answers 2 and 3 are mechanical and less precise than chemical.
An adolescent diagnosed with thalassemia major (Cooley's anemia) is at risk for which condition? 1. Hypertrophy of the thyroid 2. Hypertrophy of the thymus 3. Polycythemia vera and thrombosis 4. Chronic hypoxia and iron overload
4. Chronic hypoxia and iron overload RATIONALE: Thalassemia major increases destruction of red blood cells (RBCs), shortens the life span of RBCs, and causes anemia. The body responds by increasing RBC production, but it can't produce adequate numbers of mature cells. This process results in chronic hypoxia. In addition, children with thalassemia major require multiple transfusions of packed RBCs. The combination of excessive RBC destruction and multiple transfusions deposits excess iron that damages organs and tissues. Thalassemia major doesn't place the adolescent at risk for hypertrophy of the thymus or thyroid or polycythemia vera, which involves excessive RBC production that can lead to thrombosis.
A 13-year-old girl is being evaluated for possible Crohn's disease. The nurse expects to prepare her for which diagnostic study? 1. Genetic testing 2. Cystoscopy 3. Myelography 4. Colonoscopy with biopsy
4. Colonoscopy with biopsy RATIONALE: Crohn's disease is an inflammatory bowel disorder characterized by inflammation, ulceration, and edema of the bowel wall (typically involving the terminal ileum). Colonoscopy with biopsy are the primary procedures used to establish the diagnosis; a barium enema also may be indicated. Although genetics may play a role in Crohn's disease, genetic testing isn't part of the diagnostic workup. Cystoscopy visualizes the bladder and urinary tract and isn't indicated for this client. Myelography is a radiographic procedure used to evaluate the spinal cord.
Laboratory results for a child with a congenital heart defect with decreased pulmonary blood flow reveal an elevated hemoglobin (Hb) level, hematocrit (HCT), and red blood cell (RBC) count. These data suggest which condition? 1. Anemia 2. Dehydration 3. Jaundice 4. Compensation for hypoxia
4. Compensation for hypoxia RATIONALE: A congenital heart defect with decreased pulmonary blood flow alters blood flow through the heart and lungs, resulting in hypoxia. To compensate, the body increases the oxygen-carrying capacity of RBCs by increasing RBC production, which causes the Hb level and Hct to rise. In anemia, the Hb level and Hct typically decrease. Altered electrolyte levels and other laboratory values are better indicators of dehydration. An elevated Hb level and HCT aren't associated with jaundice.
4. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? a. Call the hospital lawyer b. Refuse to float to the ICU c. Call the nursing supervisor d. Identify tasks that can be performed safely in the ICU
4. D- Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.
A 10-month-old infant is admitted to the facility with dehydration and metabolic acidosis. What is the most common cause of dehydration and acidosis in infants? 1. Early introduction of solid foods 2. Inadequate perianal hygiene 3. Tachypnea 4. Diarrhea
4. Diarrhea RATIONALE: Diarrhea is the most common cause of dehydration and acidosis in infants. Early introduction of solid foods may cause loose stools but not dehydration or acidosis. Poor perianal hygiene may cause diaper dermatitis. Tachypnea is a sign — not a cause — of acidosis.
A nurse is assessing whether a child has received all recommended immunizations for his age. Which immunizations should he have received between ages 4 and 6? 1. Hepatitis A 2. Measles, mumps, and rubella (MMR) 3. Haemophilus influenzae, type B 4. Diphtheria, tetanus, and acellular pertussis (DTaP), MMR, and inactivated polio virus (IPV)
4. Diphtheria, tetanus, and acellular pertussis (DTaP), MMR, and inactivated polio virus (IPV) RATIONALE: Between ages 4 and 6, the child should receive DTaP, MMR, and IPV. Hepatitis A isn't a required immunization. MMR alone is incomplete and H. influenzae, type B immunization is completed by age 15 months.
A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. The physician orders a bone marrow aspiration. Place the interventions below in ascending chronological order according to their importance. Use all options. 1. Act out the procedure using a doll and biopsy kit. 2. Assure the child that the pain will go away. 3. Check the biopsy site for hemorrhage and infection. 4. Discuss the procedure with his parents. 5. Explain the discomforts that he'll feel.
4. Discuss the procedure with his parents. 1. Act out the procedure using a doll and biopsy kit. 5. Explain the discomforts that he'll feel. 2. Assure the child that the pain will go away. 3. Check the biopsy site for hemorrhage and infection. RATIONALE: The nurse must first discuss the procedure with the parents and encourage them to get involved with the plan for preparing the child. Next, the nurse should use play to teach the child about the procedure to help gain the child's confidence and put the child at ease. After the child is comfortable, the nurse can explain the discomfort he'll feel and then assure him that the pain will go away. Lastly, after the procedure, the nurse needs to check for bleeding, inflammation, and signs and symptoms of pain and infection.
A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask the nurse whether anything could have prevented this disorder. Which intervention is effective in preventing rheumatic fever? 1. Immunization with the hepatitis B vaccine 2. Isolation of individuals with rheumatic fever 3. Use of prophylactic antibiotics for invasive procedures 4. Early detection and treatment of streptococcal infections
4. Early detection and treatment of streptococcal infections RATIONALE: Rheumatic fever is a systemic inflammatory disease that follows a group A streptococcal infection. Therefore, early detection and treatment of streptococcal infections help prevent the development of rheumatic fever. Hepatitis B vaccine provides immunity against the hepatitis B virus — not streptococci. Because rheumatic fever isn't contagious, isolation measures aren't necessary. Prophylactic antibiotics are used before invasive procedures only in clients with a history of carditis to prevent bacterial endocarditis.
A nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action should the nurse take? 1. Tell the parents they should be glad their child has lived this long. 2. Point out to the parents ways in which they might have done things differently. 3. Counsel the parents on not having any more children because they could also have cystic fibrosis. 4. Encourage the parents to allow their child to follow as normal a childhood as possible.
4. Encourage the parents to allow their child to follow as normal a childhood as possible. RATIONALE: The nurse should encourage the parents to treat their child as much like a normal child as possible. The nurse should avoid being critical of how parents handle their child's condition. Children with cystic fibrosis can live productive lives well into adulthood, so telling the parents they're lucky their child has lived this long not only is rude, it's inappropriate. Although each child the couple has has a 25% chance of having cystic fibrosis, it isn't appropriate for the nurse to counsel the parents. If they express uncertainty about having more children, the nurse should refer them to their physician or a genetic counselor.
A school nurse is planning a program about skin cancer prevention for a group of teenagers. Which instruction should the nurse emphasize in her talk? 1. Stay out of the sun between 1 p.m. and 3 p.m. 2. Tanning booths are a safe alternative sun exposure for those who wish to tan. 3. Sun exposure is safe, provided the client wears protective clothing. 4. Examine skin once per month, looking for suspicious lesions or changes in moles.
4. Examine skin once per month, looking for suspicious lesions or changes in moles. RATIONALE: To detect skin cancer in its early stages, the nurse should emphasize the importance of monthly skin self-examinations and yearly examinations by a physician. To reduce the risk of skin cancer, the nurse should teach clients to avoid the sun's ultraviolet rays between 10 a.m. and 3 p.m. Repeated exposure to artificial sources of ultraviolet radiation, such as tanning booths, increases the risk of skin cancer. Although protective clothing offers some protection, some of the sun's harmful rays can penetrate clothing.
A client at 42 weeks gest is 3cm dilated, 30% effaced, with membranes intact and the fetus at +2 station. FHR is at 140-150 bpm. After 2 hours, the nurse notes on the EFM that, for the past 10 min, the FHR ranged from 160-190bpm. The client states that her baby has been extremely active. UCs are strong, occurring every 3-4 min. and lasting 40-60 sec. Which of the following findings would indicate fetal hypoxia? 1. Abnormally long UCs 2. Abnormally strong uterine intensity 3. Excessively frequent contractions with rapid fetal movement 4. Excessive fetal activity and fetal tachycardia
4. Excessive fetal activity and fetal tachycardia Fetal tachycardia and excessive fetal activity are the FIRST SIGNS OF FETAL HYPOXIA The duration of UCs is w/in normal limits. Uterine intensity can be mild-strong and still be w/in normal limit. The frequency of contractions is w/in normal limits for the active phase of labor.
A preschool-age child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect postoperative hemorrhage? 1. Vomiting of dark brown emesis 2. Refusal to drink clear fluids 3. Decreased heart rate 4. Frequent swallowing
4. Frequent swallowing RATIONALE: Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate.
A mother brings her preschool child to the emergency department after the child ingested an unknown quantity of acetaminophen. Which treatment will the physician probably order? 1. Administration of a dose of ipecac syrup 2. Insertion of a nasogastric tube and administration of an antacid 3. I.V. infusion of normal saline solution 4. Gastric lavage and administration of activated charcoal
4. Gastric lavage and administration of activated charcoal RATIONALE: The physician will probably order gastric lavage or activated charcoal administration. Ipecac syrup is no longer recommended and an antacid isn't an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting, but in itself isn't effective in eliminating the poisonous substance.
Parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they're concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to? 1. Clergy 2. Social worker 3. Certified nurse-midwife 4. Genetic counselor
4. Genetic counselor RATIONALE: A genetic counselor can educate the couple about an inherited disorder, as well as screening tests and treatments that can be done; the counselor can also provide emotional support. Clergy are available to provide spiritual support. A social worker can provide emotional support and help with referrals for financial problems. A nurse-midwife cares for women during pregnancy and birth.
An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? 1. Gloves 2. Gown and gloves 3. Gown, gloves, and mask 4. Gown, gloves, mask, and eye goggles or eye shield
4. Gown, gloves, mask, and eye goggles or eye shield RATIONALE: The transmission of SARS isn't fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a person with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.
An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is likely to help the child cope with fear and separation? 1. Ask the parents not to visit the child until he is adjusted to the new environment. 2. Ask the physician to explain to the child why he needs to stay in the health care facility. 3. Tell the child that he must act like an adult while he's in the facility. 4. Have the parents stay with the child and participate in his care.
4. Have the parents stay with the child and participate in his care. RATIONALE: Allowing the parents to stay and participate in the child's care can provide support to both the parents and the child. Asking the parents not to visit, asking the physician to explain why the child needs to stay, and telling the child to act like an adult won't address the child's diagnosis and may exacerbate the problem.
A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention? 1. Blood pressure of 95/50 mm Hg 2. Diffuse facial urticaria 3. Respiratory rate of 20 breaths/minute 4. Heart rate less than 60 beats/minute
4. Heart rate less than 60 beats/minute RATIONALE: Bradycardia, a slow but steady heartbeat at a rate less than 60 beats/minute, is an ominous sign in children. Older children experiencing anaphylaxis initially demonstrate tachycardia in response to hypoxemia. When tachycardia can no longer maintain tissue oxygenation, bradycardia follows. The development of bradycardia usually precedes cardiopulmonary arrest. The average systolic blood pressure of children ages 1 to 7 can be determined by this formula: age in years plus 90. Thus, an average blood pressure for a 5-year-old child is 95 mm Hg. Urticaria should be treated after airway control has been established. The normal respiratory rate for a 5-year-old is 20 to 25 breaths/minute
Neonates born to women infected with hepatitis B should undergo which Tx regimen 1. Hep B vaccine at birth and 1 month 2. Hep B immune globulin at birth, no hepatitis B vaccine 3. Hepatits B immune globulin within 48 hours of birth and Hep B vaccine at 1 month 4. Hep B immune globulin within 12 hours of birth and Hep B vaccine at birth, 1 month, 6 months
4. Hep B immune globulin within 12 hours of birth and Hep B vaccine at birth, 1 month, 6 months Hep B immune globulin should be given as soon as possible after birth but within 12 hours neonates should also receive hep B vaccine at regularly scheduled intervals this sequence of care has been determined as superior to the others
An infant is having his 2-month checkup at the pediatrician's office. The physician tells the parents that she's assessing for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of what joint? 1. Shoulder 2. Elbow 3. Knee 4. Hip
4. Hip RATIONALE: To assess for Ortolani's sign, the nurse abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.
A client has a diabetic stasis ulcer on the lower leg. The nurse uses a hydrocolloid dressing to cover it. The procedure for application includes: 1. Cleaning the skin and wound with betadine 2. Removing all traces of residues for the old dressing 3. Choosing a dressing no more than quarter-inch larger than the wound size 4. Holding in place for one minute to allow it to adhere
4. Holding in place for one minute to allow it to adhere; The skin is cleansed with normal saline or a mild cleanser. Residue of old dressings will dissolve. The dressing size is to be 3-4 cm (1.5 inches) larger than the size of the wound.
A 14-year-old girl in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the girl's need to achieve what developmental milestone? 1. Autonomy 2. Initiative 3. Industry 4. Identity
4. Identity RATIONALE: According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. When an adolescent is hospitalized, she is separated from her peer group and her body image may be altered. This alteration in body image may interfere with the ongoing development of her identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.
A 2-year-old child in the cardiac step-down unit is experiencing supraventricular tachycardia. Which intervention should be attempted first? 1. Administering digoxin (Lanoxin) I.V. 2. Administering verapamil (Calan) I.V. 3. Administering synchronized cardioversion 4. Immersing the child's hands in cold water
4. Immersing the child's hands in cold water RATIONALE: Vagal maneuvers, such as immersing the child's hands in cold water, are commonly tried first as a mechanism to decrease heart rate. Other vagal maneuvers include breath-holding, gagging, and placing the child's head lower than the rest of the body. Digoxin may be given after vagal maneuvers to help decrease heart rate; verapamil isn't recommended. Synchronized cardioversion may be necessary if vagal maneuvers fail and drugs are ineffective.
A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider? 1. Inappropriate parental concern for the degree of injury 2. Absence of parents to question about the injury 3. Inappropriate response of the child to the injury 4. Incompatibility between the child's history and the injury
4. Incompatibility between the child's history and the injury RATIONALE: Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. For example, the child may have a skull fracture but the parents state that the child fell off of the sofa. The other criteria also may suggest child abuse but are less reliable indicators.
A nurse is providing care to a 5-year-old child with a fractured femur whose nursing diagnosis is Imbalanced nutrition: Less than body requirements. Which change is most likely to occur with this condition? 1. Decreased protein catabolism 2. Increased calorie intake 3. Increased digestive enzymes 4. Increased carbohydrate need
4. Increased carbohydrate need RATIONALE: Increased carbohydrate need is most likely because healing and repair of tissue requires more carbohydrates. Increased — not decreased — protein catabolism is present and decreased appetite — not increased — is a problem. Digestive enzymes are decreased — not increased.
Why is a client with fever often predisposed to pressure ulcers? 1. Pain perception is diminished. 2. Medications given to relieve fever cause edema. 3. The client may be too weak to change position. 4. Increased metabolism causes increased oxygen needs that cannot be met.
4. Increased metabolism causes increased oxygen needs that cannot be met; Increased metabolism causes increased oxygen needs that cannot be met; therefore, a client with a fever is predisposed to pressure ulcers. Answers 1 and 2 are false statements. Answer 3 may be a cause of pressure ulcers and may occur in clients with fever, but it is not directly related.
Which factor will most likely decrease drug metabolism during infancy? 1. Decreased glomerular filtration 2. Reduced protein-binding ability 3. Increased tubular secretion 4. Inefficient liver function
4. Inefficient liver function RATIONALE: Inefficient liver function will most likely decrease drug metabolism during infancy. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism; reduced protein-binding ability may affect drug distribution but not metabolism.
A mother is discontinuing breast-feeding after 5 months. What should the nurse advise the mother to include in her infant's diet? 1. Iron-rich formula and baby food 2. Whole milk and baby food 3. Skim milk and baby food 4. Iron-rich formula alone
4. Iron-rich formula alone RATIONALE: The American Academy of Pediatrics recommends iron-rich formula for 5-month-old infants and cautions against giving infants solid food — even baby food — until age 6 months. The Academy doesn't recommend whole milk before age 12 months or skim milk before age 2 years.
A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? 1. Vomiting 2. Papilledema 3. Vital sign changes 4. Irritability
4. Irritability RATIONALE: An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration.
An infant arrives at the emergency department in full cardiopulmonary arrest. Efforts at resuscitation fail, and he's pronounced dead. The cause of death is sudden infant death syndrome (SIDS). Which statement regarding the etiology of SIDS is true? 1. It occurs in suspected child abuse cases. 2. It occurs primarily in infants with congenital lung problems. 3. It occurs only in premature infants. 4. It occurs more commonly in infants who sleep in the prone position.
4. It occurs more commonly in infants who sleep in the prone position. RATIONALE: More infants who sleep in the prone position are affected by SIDS. Because of the pooling of blood that occurs in the child with SIDS, child abuse is sometimes suspected. Although premature infants are at a higher risk for SIDS, SIDS isn't exclusive to them. No correlation between SIDS and lung disease exists.
Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery? 1. Have the child take off his own underwear. 2. Encourage the child to use the hospital blanket as a transition object so his won't be lost. 3. Let the child choose which parent can accompany him to the preoperative waiting area. 4. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.
4. Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon. RATIONALE: Giving the child a choice would promote cooperation, and children commonly prefer a nonthreatening method of travel such as a wagon. Having the child take off his own underwear isn't appropriate because preschoolers commonly have a fear of genital mutilation; the child would likely resist removing his underwear. Children usually won't transfer feelings of security objects to another object such as a hospital blanket. Both parents are encouraged to accompany the child to the preoperative area, so having the child choose one parent isn't appropriate.
A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff? 1. Proper documentation of a verbal order from a physician 2. Policy changes in the administration of opioids 3. New education materials for the management of diabetes 4. Logging off a computer containing client information
4. Logging off a computer containing client information RATIONALE: All members of the health care team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.
A child, age 9, is admitted to the emergency department with abdominal pain. The child's mother states the pain began about 12 hours ago. The nurse notes the child has a temperature of 100.8° F (38.2° C) and nausea. The child vomited once. Which abdominal area would be most appropriate for the nurse to assess? 1. Left lower abdominal quadrant 2. Right upper abdominal quadrant 3. Left upper abdominal quadrant 4. Lower right abdominal quadrant
4. Lower right abdominal quadrant RATIONALE: The child's symptoms indicate appendicitis. Therefore, the nurse should assess the lower right abdominal quadrant. The nurse would assess the left lower abdominal quadrant to detect descending and sigmoid colon problems; right upper quadrant to detect gallbladder disease; and the left upper quadrant to detect pancreatitis.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child? 1. Encouraging the infant to hold a bottle 2. Keeping the infant on bed rest to conserve energy 3. Rotating caregivers to provide more stimulation 4. Maintaining a consistent, structured environment
4. Maintaining a consistent, structured environment RATIONALE: The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
What should a nurse do to ensure a safe hospital environment for a toddler? 1. Place the child in a youth bed. 2. Move stacking toys out of reach. 3. Pad the crib rails. 4. Move the equipment out of reach.
4. Move the equipment out of reach. RATIONALE: Moving the equipment out of reach ensures a safe environment because toddlers are curious and may try to play with items within their reach. Toddlers in a strange hospital environment still need the security of a crib. Stacking toys don't need to be moved out of reach because they don't present a safety hazard and are appropriate for this age-group. Padded crib rails are necessary only if seizure activity is present.
A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved
4. Not crying when moved RATIONALE: Not crying when moved most strongly suggests child abuse because a victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills.
Parents of a preschooler are told their child needs a blood transfusion to treat hypovolemia. A nurse contacts a physician with the information that the parent's are Jehovah's Witnesses and refuse to sign the consent form. The physician tells the nurse to perform the transfusion. He states that he isn't going to let the child's parents allow him to die. What should the nurse do next? 1. Contact social services and allow that agency to manage the situation. 2. Perform the blood transfusion as directed by the physician. 3. Inform the boy's parents of the physician's decision and ask them to reconsider. 4. Not perform the transfusion but provide comfort measures for the child.
4. Not perform the transfusion but provide comfort measures for the child. RATIONALE: Jehovah's Witnesses believe that a blood transfusion is the same as oral intake of blood, which they regard as a sin. The nurse caring for the child shouldn't perform the transfusion, but she should provide comfort measures for the child. It isn't appropriate for the nurse to call social services because this situation is an ethical matter. The nurse shouldn't ask the parents to reconsider their decision because it violates their cultural beliefs, which the nurse should uphold.
A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first? 1. Firmly tell the father he must leave. 2. Notify the nursing coordinator on duty. 3. Notify the nurse-manager. 4. Notify hospital security or the local authorities.
4. Notify hospital security or the local authorities. RATIONALE: The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place her and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.
Which intervention takes priority when admitting an infant with acute gastroenteritis? 1. Obtaining a stool specimen 2. Weighing the infant 3. Offering the infant clear liquids 4. Obtaining a history of the illness
4. Obtaining a history of the illness RATIONALE: Obtaining a history of the infant's illness takes priority because the history helps with developing a treatment plan. Getting a stool specimen and weighing the infant can follow taking the history. The nurse shouldn't offer clear liquids because they increase the risk of vomiting, which may worsen the infant's dehydration.
A nurse is reviewing a care plan for an infant undergoing phototherapy for hyperbilirubinemia. Which intervention should the nurse remove from the care plan? 1. Repositioning the infant frequently to expose all body surfaces 2. Obtaining frequent serum bilirubin levels 3. Shielding the infant's eyes with an opaque mask to prevent exposure to the light 4. Performing frequent visual assessments of jaundice
4. Performing frequent visual assessments of jaundice RATIONALE: Visual assessment of jaundice isn't a valid method for assessing jaundice. Serum bilirubin levels must be checked every 4 to 12 hours. Repositioning the infant and shielding the infant's eyes are appropriate interventions for an infant undergoing phototherapy and should be included in the care plan.
A toddler requires emergency intervention for an obstructed airway. Which nursing intervention is appropriate? 1. Hyperextending the child's neck to open the airway and delivering four rescue breaths 2. Placing the child on the side and using a blind finger sweep to remove the foreign object 3. Delivering five back blows followed by five chest thrusts 4. Performing the tongue-jaw lift and removing the foreign object only if it's visible.
4. Performing the tongue-jaw lift and removing the foreign object only if it's visible. RATIONALE: When checking for a foreign object in the airway of a child younger than age 8, the rescuer should perform the tongue-jaw lift and remove the object only if it's visible. Neck hyperextension may occlude the airway; the head tilt/chin lift method is the correct way to open the airway. After checking for a foreign object, the rescuer should open the airway and attempt to deliver two rescue breaths. A blind finger sweep is contraindicated because it may push the object into the airway. Abdominal thrusts (the Heimlich maneuver) are indicated only for children older than age 1. In a child younger than age 1, such thrusts may injure the abdominal organs; back blows and chest thrusts should be used instead.
What is the recommended treatment for scabies in a child who's younger than age 1? 1. Griseofulvin (Grifulvin V) 2. Tolnaftate (Tinactin) 3. Thiabendazole (Mintezol) 4. Permethrin (Elimite)
4. Permethrin (Elimite) RATIONALE: Permethrin, supplied in a cream, is the treatment of choice for children younger than age 1. However, its safety hasn't been established for clients younger than 2 months. Griseofulvin and tolnaftate are used to treat ringworm, not scabies. Thiabendazole is used to treat hookworm, roundworm, threadworm, and whipworm.
A school-age child is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child's risk of infection? 1. Implementing reverse isolation 2. Maintaining standard precautions 3. Requiring staff and visitors to wear masks 4. Practicing thorough hand washing
4. Practicing thorough hand washing RATIONALE: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.
An infant requires cardiorespiratory monitoring. A nurse must locate and clean the necessary equipment, move it into the infant's room, and secure it to the bedside wall-mounting device. Which principles should a nurse use to complete this task safely? 1. Principles of geometry and mathematics 2. Principles of ergonomics and geometry 3. Principles of sterile technique and mathematics 4. Principles of infection control and ergonomics
4. Principles of infection control and ergonomics RATIONALE: Properly cleaning the monitoring equipment involves infection control. Properly placing and securing the monitor uses ergonomic principles. The principles of geometry and mathematics aren't relevant to safety.
When assessing a child with bronchiolitis, which finding does the nurse expect? 1. Clubbed fingers 2. Barrel chest 3. Barking cough and stridor 4. Productive cough
4. Productive cough RATIONALE: Bronchiolitis causes a productive cough. Clubbed fingers and a barrel chest are more likely in a client with chronic respiratory problems. A barking cough is associated with croup.
When attempting to facilitate spiritual support for a school-age child with a life-threatening disease and his family, which action would hinder the nurse-client relationship? 1. Becoming familiar with the family's spiritual beliefs and practices 2. Seeking assistance or referrals to the facility chaplain or other resources 3. Being open to the family's and the child's expressions of spiritual concerns 4. Promoting the nurse's personal values and beliefs if she considers the family's to be inappropriate
4. Promoting the nurse's personal values and beliefs if she considers the family's to be inappropriate RATIONALE: If the nurse attempts to force her beliefs on the family, the family may interpret this as a lack of understanding, which could lead to distrust of the nurse. Becoming familiar with the family's spiritual beliefs and practices, seeking assistance or referrals to the facility chaplain or other resources, and being open to the family's and the child's expressions of spiritual concerns are all ways to help children and their families cope with a life-threatening illness.
A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic. The infant's anterior fontanel is sunken. What other assessment data are a priority for the nurse to collect? 1. Temperature, pulse, and respiratory rate 2. Pulse, respiratory rate and skin turgor 3. Respiratory rate, skin and turgor 4. Pulse, skin turgor, and number of wet diapers the infant had in the last 24 hours
4. Pulse, skin turgor, and number of wet diapers the infant had in the last 24 hours RATIONALE: A sunken fontanel indicates dehydration. The nurse should assess pulse, skin turgor, and the number of wet diapers the infant had in the past 24 hours. These findings help evaluate the extent of dehydration. Temperature and respiratory rate may also be assessed, but these assessments don't provide the same detail about dehydration as pulse, skin turgor, and number of wet diapers.
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: 1. Sanguineous 2. Serous-sanguineous 3. Serous 4. Purulent
4. Purulent; Drainage is described as purulent. Sanguineous and Serous-sanguineous contain blood. Serous is clear and watery.
A 2-month-old infant is brought to the clinic by his mother. His abdomen is distended, and he has been vomiting forcefully and with increasing frequency over the past 2 weeks. On examination, the nurse notes signs of dehydration and a palpable mass to the right of the umbilicus. Peristaltic waves are visible, moving from left to right. The nurse should suspect which condition? 1. Colic 2. Failure to thrive 3. Intussusception 4. Pyloric stenosis
4. Pyloric stenosis RATIONALE: Abdominal distention, forceful vomiting, dehydration, a palpable mass, and visible peristatic waves are classic symptoms of pyloric stenosis caused by hypertrophy of the circular pylorus muscle. Abdominal masses and abnormal peristalsis aren't necessarily related to colic or failure to thrive. Intussusception is usually characterized by acute onset and severe abdominal pain.
Which activity should a 2-year-old child be able to do? 1. Build a tower of eight cubes. 2. Point out a picture. 3. Wash and dry his hands. 4. Remove a garment.
4. Remove a garment. RATIONALE: According to the Denver Developmental Screening Test, most 2-year-olds are able to remove one garment. A 2½-year-old can build a tower of eight cubes and point out a picture. A 3-year-old can wash and dry his hands.
A nurse suspects that a toddler, who is admitted to the pediatric unit, has been physically abused by his mother. What is the nurse required to do? 1. Talk with the child about she suspects. 2. Confront the mother with her suspicions. 3. Discuss the case with another nurse during lunch break. 4. Report the case to local authorities.
4. Report the case to local authorities. RATIONALE: The nurse is required to report the case to local authorities because every state in the United States has laws for mandatory reporting of suspected child abuse and neglect. These cases are then referred to local agencies, such as Child Protective Services, for investigation. Social workers should be consulted before approaching a child and discussing child abuse. Confronting the mother could increase the risk of harm to the child and to the nurse. Discussing the case with another nurse breaches the client's confidentiality.
A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? 1. Reverse isolation 2. Strict hand washing 3. Standard precautions 4. Respiratory isolation
4. Respiratory isolation RATIONALE: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.
A female adolescent client refuses to allow male nurses to care for her while she's hospitalized. Which of these health care rights is this adolescent exerting? 1. Right to competent care 2. Right to have an advance directive on file 3. Right to confidentiality of her medical record 4. Right to privacy
4. Right to privacy RATIONALE: This adolescent is exhibiting her right to privacy when she requests that she doesn't want a male nurse to care for her. She also has a right to competent care, the right to have an advance directive on file, and a right to confidentiality. However, she isn't exercising these rights in this scenario.
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? 1. Single-hole nipple 2. Plastic spoon 3. Paper straw 4. Rubber dropper
4. Rubber dropper RATIONALE: An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma. A single-hole nipple, a plastic spoon, and a paper straw wouldn't prevent these actions.
An infant, age 6 weeks, is brought to the clinic for a well-baby visit. To assess the fontanels, how should the nurse position the infant? 1. Supine 2. Prone 3. In the left lateral position 4. Seated upright
4. Seated upright RATIONALE: For the most accurate results, the nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense. When the infant is in a recumbent position, the fontanel is less flat than it is normally, creating the false impression that intracranial pressure is increased.
A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate? 1. Mixing the medication in milk so the child isn't aware that it's there 2. Explaining the medication's effects in detail to ensure cooperation 3. Making the child feel ashamed for not cooperating 4. Showing trust in the child's ability to cooperate even with an unpleasant procedure
4. Showing trust in the child's ability to cooperate even with an unpleasant procedure RATIONALE: To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.
Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital? 1. Crayons and paper 2. Stuffed teddy bear in the crib 3. Mobile hanging over the crib 4. Side rails in the halfway position
4. Side rails in the halfway position RATIONALE: Side rails in the halfway position pose the biggest threat because the most common accidents in hospitals are falls. To prevent falls, the crib rails always should be raised and fastened securely unless an adult is at the bedside. Crayons and paper and a stuffed teddy bear are safe toys for a 2-year-old child. Although a mobile could pose a safety threat to this child, the threat is less serious than that posed by an incorrectly positioned side rail.
Parents of a school-age child with asthma express concern about letting the child participate in sports. What should the nurse tell the parents about the relationship between exercise and asthma? 1. Asthma attacks are triggered by allergens, not exercise. 2. The child should avoid exercise because it may trigger asthma attacks. 3. Continuous activities such as jogging are less likely to trigger asthma than intermittent activities such as baseball. 4. Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports.
4. Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports. RATIONALE: Although exercise may trigger asthma attacks, the nurse should tell the parents that taking prophylactic asthma drugs before beginning the activity can prevent attacks, enabling the child to engage in most sports. To say asthma attacks are triggered by allergens, but not exercise, isn't appropriate because asthma attacks may be triggered by various factors, including allergens, exercise, medications, upper respiratory tract infections, and psychological stress. Provided the asthma is under control, most children can participate in sports and other physical activities; in fact, they benefit from exercise. Activity restrictions actually hamper peer interaction, which is essential to the development of the school-age child. A child with asthma may tolerate intermittent activities better than continuous ones.
A nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which observation indicates that teaching has been effective? 1. The toddler stays neat while eating. 2. The toddler finishes the meal within a specified period of time. 3. The child lies down to rest after eating. 4. The child eats finger foods by himself.
4. The child eats finger foods by himself. RATIONALE: The child eating finger foods by himself indicates effective teaching because a child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to feed himself. Because spasticity affects coordinated chewing and swallowing as well as the ability to bring food to the mouth, it's difficult for the child with cerebral palsy to eat neatly. In terms of a specified period of time, the child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing shouldn't be rushed. A child shouldn't lie down to rest after eating because doing so may cause the child to vomit from a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.
A nurse is caring for a child with tetralogy of Fallot. The child's mother becomes concerned when she visits her son and notices him sucking his thumb, a behavior that he had previously given up. What does this behavior indicate? 1. The child is depressed. 2. The child is in pain. 3. The child wants attention. 4. The child is responding to stress.
4. The child is responding to stress. RATIONALE: This behavior indicates the child is responding to stress. Regression (reverting back to previously outgrown behaviors) is a common response to stressful situations. The nurse should reassure the parents that thumb sucking and other regressive behaviors should disappear after the stressful situation is resolved. Thumb sucking isn't a sign of depression or pain or an attention-seeking behavior.
37. The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor. Company. Kindle Edition.
4. The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.
A 10-year-old child is in the hospital for the first time. The nurse has provided support and teaching to help the family and child adjust and to reduce their anxiety related to the child's hospitalization. Which situation indicates more teaching is needed? 1. The parents relate readily with the staff and calmly with the child. 2. The child accepts and responds positively to comforting measures. 3. The child discusses procedures and activities without evidence of anxiety. 4. The parents choose to leave to let the child build a relationship with the staff.
4. The parents choose to leave to let the child build a relationship with the staff. RATIONALE: The parents leaving indicates more teaching is needed. The parents of an adolescent might leave to help the teen maintain a fragile identity, but a 10-year-old child would prefer to have his parents with him. Expected outcomes of support and teaching for a child and parents new to the hospital would include the parents' relating readily to the staff and calmly with the child, the child's accepting and responding positively to comforting measures, and the child's discussing procedures and activities without evidence of anxiety.
A toddler is hospitalized for treatment of injuries that the staff believes were caused by child abuse. A staff member states that the parents "shouldn't be allowed to visit because they caused the child's injuries." When responding to this staff member, the nurse should base the comments on which understanding? 1. The parents shouldn't be allowed to visit the child. 2. The parents shouldn't visit until the child is ready for discharge. 3. The parents should visit on a schedule established by the health care team and should be supervised during visits. 4. The parents should be encouraged to visit frequently and should be welcomed by the staff.
4. The parents should be encouraged to visit frequently and should be welcomed by the staff. RATIONALE: Abusive parents should be encouraged to visit their child frequently and should be welcomed by the staff. Many abusive parents love their children but lack effective parenting skills. The child's hospitalization offers an opportunity for the staff to demonstrate appropriate parenting behaviors to the parents.
Which desired outcome demonstrates effective parent teaching about disciplining a toddler? 1. The parents will set flexible rules. 2. The parents will verbalize requests for behavior in negative terms. 3. The parents will raise their voices when reprimanding the child. 4. The parents will call immediate attention to undesirable behavior.
4. The parents will call immediate attention to undesirable behavior. RATIONALE: Calling immediate attention to undesirable behavior reflects effective teaching. This approach helps the child learn socially acceptable behavior and maintain self-esteem and a positive self-concept while learning to adapt to the rules of the larger group and society. Rules should be established clearly and enforced consistently. To reinforce desirable behavior, parents should voice requests for behavior in positive terms and use a normal speaking voice and tone when talking to or reprimanding the child. Screaming and shouting should be minimized.
A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention? 1. One leg is slightly cooler than the other leg. 2. The leg used for the catheter insertion is slightly paler than the other leg. 3. A small amount of bright red blood is seen on the dressing. 4. The pedal pulse of the right leg isn't detectable.
4. The pedal pulse of the right leg isn't detectable. RATIONALE: Using the femoral vein during catheterization can cause the affected blood vessels to spasm or cause a blood clot to develop, altering circulation in the leg. The inability to detect the pedal pulse in the affected leg is an ominous sign and requires immediate intervention. Small amounts of coolness or pallor are normal. These findings should improve. Although the nurse should continue to monitor a dressing with a small amount of blood on it, this finding isn't the priority in this situation.
Which assessment finding in a 4-month-old infant is a concern? 1. The abdominal wall is rising with inspiration. 2. The respiratory rate is between 30 and 35 breaths/minute. 3. The infant's skin is mottled during examination. 4. The spaces between the ribs (intercostal) are delineated during inspiration.
4. The spaces between the ribs (intercostal) are delineated during inspiration. RATIONALE: The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers; after that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute; a rate between 30 and 35 breaths/minute is within this normal range. An infant's skin can become mottled if the infant is left uncovered during the examination; this change isn't a cause for concern.
A nurse manager of the pediatric unit discovers that she's overbudget on supplies. How could each nurse assigned to the unit help with cost containment? 1. Order only brand-name supplies instead of the generic equivalent. 2. Use the supply closet at work to stock personal medicine cabinets because the supplies are free. 3. Offer clients' parents the use of unit phones. 4. Use care pathways to specify care and identify daily outcomes.
4. Use care pathways to specify care and identify daily outcomes. RATIONALE: Using care pathways to specify care and identify daily outcomes ensures that clients progress toward a timely discharge and that resources are used appropriately. A longer hospital stay requires more resources, which, in turn, leads to a more costly health care bill. Generic brands are less expensive than brand name products; therefore, their use should be encouraged. Filling a personal medicine cabinet with supplies from work constitutes stealing and offering the unit phones to parents generates higher phone bills.
When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration? 1. Administering the oral medication as quickly as possible 2. Placing the medication in the infant's formula bottle 3. Keeping the infant upright with the nasal passages blocked 4. Using an oral syringe to place the medication beside the tongue.
4. Using an oral syringe to place the medication beside the tongue. RATIONALE: Using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly could cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and because the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.
When administering an I.M. injection to an infant, the nurse should use which site? 1. Deltoid 2. Dorsogluteal 3. Ventrogluteal 4. Vastus lateralis
4. Vastus lateralis RATIONALE: The recommended injection site for an infant is the vastus lateralis or rectus femoris muscle. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.
A school nurse is examining a student at an elementary school. Which findings would lead the nurse to suspect impetigo? 1. Small, red lesions on the trunk and in the skin folds 2. A discrete pink-red maculopapular rash that starts on the head and progresses down the body 3. Red spots with a blue base found on the buccal membranes 4. Vesicular lesions that ooze, forming crusts on the face and extremities
4. Vesicular lesions that ooze, forming crusts on the face and extremities RATIONALE: Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most commonly on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Red spots with a blue base found on the buccal membranes, known as Koplik's spots, are characteristic of measles (rubeola).
A child is receiving chemotherapy for treatment of acute lymphocytic leukemia. During discharge preparation, which topic is most important for the nurse to discuss with the child and parents? 1. How to help the child adjust to an altered body image 2. How to increase the child's interactions with peers 3. The need to decrease the child's activity level 4. Ways to prevent infection
4. Ways to prevent infection RATIONALE: Because overwhelming infection is the most common cause of death in clients with leukemia, preventing infection is the most important teaching topic. Although promoting adjustment to an altered body image and increasing peer interactions are important, they don't address life-threatening concerns and therefore take lower priority. The nurse should advise the parents to let the child's desire and tolerance for activity determine the child's activity level.
A toddler is hospitalized for evaluation and management of congenital heart disease (CHD). During discharge preparation, the nurse should discuss which topic with the parents? 1. The need to withhold childhood immunizations 2. The importance of restricting the child's fat intake 3. How to perform postural drainage 4. When to administer prophylactic antibiotics
4. When to administer prophylactic antibiotics RATIONALE: In CHD, areas of turbulent blood flow provide an optimal environment for bacterial growth. Therefore, a child with CHD is at increased risk for bacterial endocarditis, an infection of the heart valves and lining, and requires prophylactic antibiotics before dental work and invasive procedures. These children should receive all childhood immunizations. They don't require postural drainage or dietary fat restriction.
A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions? 1. With the fingers of one hand 2. With two fingertips 3. With the palm of one hand 4. With the heel of one hand
4. With the heel of one hand RATIONALE: When performing CPR on a child between ages 1 and 8, the nurse should use the heel of one hand to compress the chest one-third to one-half the depth of the chest. Using only the fingers of one hand isn't appropriate for CPR. The use of two fingertips is appropriate for infant CPR but this method can't compress the chest sufficiently on an older child. The palm is never used for chest compressions in CPR.
A 4-month-old infant is taken to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the infant has failed to gain expected weight and recommends that the infant have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that: 1. the baby will need to fast before the test. 2. a sample of blood will be necessary. 3. a low-sodium diet is necessary for 24 hours before the test. 4. a low-intensity, painless electrical current is applied to the skin.
4. a low-intensity, painless electrical current is applied to the skin. RATIONALE: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. The nurse should explain to the parents that after pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test.
A child experiences nausea and vomiting after receiving cancer chemotherapy drugs. To help prevent these problems from recurring, the nurse should: 1. provide a high-fiber diet before the next chemotherapy session. 2. administer allopurinol (Zyloprim) 2 hours before the next chemotherapy session. 3. encourage increased fluid intake before the next chemotherapy session. 4. administer an antiemetic 30 to 60 minutes before the next chemotherapy session.
4. administer an antiemetic 30 to 60 minutes before the next chemotherapy session. RATIONALE: The nurse should administer an antiemetic 30 to 60 minutes before the chemotherapy session because antiemetics counteract nausea most effectively when given before administration of an agent that causes nausea. Antiemetics also work better when given continuously rather than as needed. A high-fiber diet or allopurinol wouldn't prevent or reduce nausea and vomiting. Increasing fluid intake before the next chemotherapy session would only worsen the nausea and could cause more vomiting.
A client in early labor states that she has a thick yellow discharge from both of her breasts. Which of the following actions by the nurse would be correct? 1. tell her that her milk is starting to come in bc she's in labor 2. complete a thorough breast exam and document the results in the chart. 3. perform a culture on the discharge and inform the client that she might have mastitis 4. inform the client that the discharge is colostrum, normally present after the 4th month of preg.
4. after the 4th month, colostrum may be expressed. the breasts normally produce colostrum for the first few days after delivery. milk production begins 1-3 days PP A clinical breast exam isnt indicated in intrapartum although a culture may be indicated, it requires advanced assessment as well as a medical order
A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the 2-year-old child is to: 1. expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible. 2. ask the mother to wait briefly outside until the assessment is over. 3. tell the child the nurse is going to listen to his chest with the stethoscope. 4. allow the child to handle the stethoscope before listening to his lungs.
4. allow the child to handle the stethoscope before listening to his lungs. RATIONALE: The best way to approach the 2-year-old is to allow the child to handle the stethoscope because toddlers are naturally curious about their environment. Letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should only expose one area at a time during assessment and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child and to comfort the child with objects with which he's familiar, and the child should be given limited choices to allow autonomy such as, "Do you want me to listen first to the front of your chest or your back?"
A nurse is assessing a 15-year-old girl who has lost 30 lb (13.6 kg) over 3 months. What other finding is the nurse likely to assess? 1. insomnia. 2. dysphagia. 3. diarrhea. 4. amenorrhea.
4. amenorrhea. RATIONALE: Amenorrhea is common finding in girls and women with anorexia nervosa. Researchers don't know whether the condition results from starvation or from an underlying metabolic disturbance. Insomnia isn't associated with anorexia nervosa. Clients with anorexia nervosa are capable of eating and rarely have dysphagia (difficulty swallowing). Anorexia nervosa is more likely to cause constipation than diarrhea because limited oral intake decreases GI motility.
A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: 1. a depressed fontanel. 2. slurred speech. 3. tachycardia. 4. an altered level of consciousness.
4. an altered level of consciousness. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.
A physician orders digoxin (Lanoxin) elixir for a toddler with heart failure. Immediately before administering this drug, the nurse must check the toddler's: 1. serum sodium level. 2. urine output. 3. weight. 4. apical pulse.
4. apical pulse. RATIONALE: Because digoxin may reduce the heart rate and heart failure may cause a pulse deficit, the nurse should measure the toddler's apical pulse before administering the drug to prevent further slowing of the heart rate. The serum sodium level doesn't affect digoxin's action. For a child with heart failure, the nurse should check urine output and measure weight regularly, but not necessarily just before digoxin administration.
The parents of a healthy infant request information about advance directives. The nurse's best response is to: 1. suggest that the parents discuss the matter with an attorney. 2. tell the parents that they should discuss advance directives with the physician. 3. provide the parents with a brochure about advance directives. 4. ask open-ended questions about the parents' concerns.
4. ask open-ended questions about the parents' concerns. RATIONALE: Asking open-ended questions about the parents' concerns will help the nurse understand why they're asking for information. Advance directives are rarely prepared for healthy infants. The parents' request for information may indicate distress, and the nurse should obtain more details before giving them information. Although suggesting the parents talk to their attorney or to the physician and providing the parents with a brochure about advance directives are appropriate actions, the nurse must obtain additional information before implementing these choices.
A nurse works in the neonatal intensive care unit. Her responsibility for disaster planning includes: 1. developing the plan for disaster response and conducting weekly practice drills. 2. following the disaster coordinator's instructions if a disaster occurs. 3. ensuring the safety of all neonates in the disaster area. 4. collaborating in development and implementation of the plan.
4. collaborating in development and implementation of the plan. RATIONALE: Collaboration is crucial in developing a disaster plan. Nurses must take an active role in disaster planning, but nurses aren't solely responsible for planning disaster response and conducting practice drills. Although the nurse should try to make sure that the neonates are safe during a disaster, she can't ensure on her own that all of them will be safe.
Parents of a school-age child request anticipatory guidance. When developing a care plan to address this matter, the nurse should keep in mind that this child's cognitive development is characterized by: 1. magical thinking. 2. transductive reasoning. 3. abstract thought. 4. conservation skills.
4. conservation skills. RATIONALE: According to Piaget, a school-age child acquires cognitive operations to understand concepts related to objects, including conservation skills, classification skills, and combinational skills. Magical thinking and transductive reasoning are characteristic of the preschooler's preoperational thought. Abstract thought is characteristic of the adolescent's period of formal operations.
A nurse is caring for a toddler in respiratory distress. She is gathering supplies to help with endotracheal intubation. The nurse knows the physician will use an uncuffed endotracheal tube because the: 1. vocal cords provide a natural seal. 2. trachea is shorter. 3. larynx is anterior and cephalad. 4. cricoid cartilage is the narrowest part of the larynx.
4. cricoid cartilage is the narrowest part of the larynx. RATIONALE: An uncuffed endotracheal tube is used because the cricoid cartilage in the toddler is the narrowest part of the larynx and provides a natural seal. This aspect keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. Although the trachea is shorter and the larynx is anterior and cephalad, these aren't reasons to choose an uncuffed tube.
A 3-year-old Vietnamese child with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, weltlike lesions on the child's upper back and chest. The nurse should consider that these lesions may be caused by: 1. shingles. 2. child abuse. 3. allergic reaction. 4. cultural practice.
4. cultural practice. RATIONALE: The nurse should consider that the lesions may be caused by cultural practice. Many Vietnamese perform coining, a cultural practice in which a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of a disease. Coining can produce weltlike lesions on the child's back or chest, and children subjected to the practice are commonly thought to have been abused. Interviewing the family and assessing its cultural background help distinguish between abuse and culture practice. Shingles, a form of herpes zoster, is a communicable disease usually affecting immunocompromised individuals and older adults. The disease produces small crusty pustules on the lower back and trunk. The description of the lesions doesn't fit those produced by an allergic reaction.
According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by: 1. emphasizing the need to follow the facility regimen. 2. allowing parents and siblings to visit frequently. 3. arranging for tutoring in school work. 4. encouraging peer visitation.
4. encouraging peer visitation. RATIONALE: Peer visitation gives the adolescent an opportunity to continue along his path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect his development. To achieve a sense of identity, the adolescent must gain independence from his family. Tutoring may help him maintain a positive self-image relative to his schoolwork but doesn't affect his development.
In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has: 1. a lower percentage of body water than an adult. 2. a lower daily fluid requirement than an adult. 3. a more rapid respiratory rate than an adult. 4. immature kidney function.
4. immature kidney function. RATIONALE: Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant actually has a greater percentage of body water as well as higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid balance in an infant.
A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: 1. using sterile surgical scrubs. 2. preoperative cleansing of jewelry worn by the surgical team. 3. applying bandages to cover any wounds surgical team members have. 4. performing a preoperative surgical scrub for at least 3 to 5 minutes.
4. performing a preoperative surgical scrub for at least 3 to 5 minutes. RATIONALE: The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.
The SGA neonate is at increased risk during the transitional period for which complication? 1. anemia probably due to chronic fetal hypoxia 2. hyperthermia due to decreased glycogen stores 3. hyperglycemia due to decreased glycogen stores 4. polycythemia probably due to chronic fetal hypoxia
4. polycythemia probably due to chronic fetal hypoxia the SGA baby is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia the neonates are also at increased risk for developing hypoglycemia due to decreased glycogen stores
A nurse plans a conference to discuss the care plan for an infant admitted to the hospital with a diagnosis of nonorganic failure to thrive. Appropriate participants in the care conference include the: 1. registered nurse (RN), physician, social worker, and infant's parents. 2. social worker, RN, occupational therapist, and dietitian. 3. infant's primary caregiver, RN, physician, and occupational therapist. 4. registered dietitian, RN, physician, and infant's primary caregiver.
4. registered dietitian, RN, physician, and infant's primary caregiver. RATIONALE : The registered dietitian, RN, physician, and infant's primary caregiver are crucial interdisciplinary team members who should participate in this care conference. The dietitian can address nutritional needs. The primary caregiver can provide input. The social worker and occupational therapist may become involved after the infant's condition improves, but they aren't crucial members of the team at this point.
When caring for a 12-month-old infant with dehydration and metabolic acidosis, the nurse expects to see: 1. a reduced white blood cell (WBC) count. 2. a decreased platelet count. 3. shallow respirations. 4. tachypnea.
4. tachypnea. RATIONALE: The nurse would expect to see tachypnea because the body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. Altered WBC and platelet counts aren't specific signs of metabolic imbalance.
A child, age 5, takes amoxicillin (Amoxil) orally three times per day to treat otitis media. For the most accurate calculation of a safe dosage, the nurse should use: 1. the child's weight in kilograms. 2. Young's rule based on the child's age. 3. Clark's rule based on the child's weight in pounds. 4. the child's body surface area.
4. the child's body surface area. RATIONALE: Using a child's body surface area may be the most accurate method for calculating safe drug dosages because body surface area is thought to parallel the child's organ growth and maturation and metabolic rate. Using the child's weight in kilograms, Young's rule based on the child's age, or Clark's rule based on the child's weight in pounds is likely to yield less accurate dosages.
A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should: 1. compress the sternum with both hands at a depth of 1½″ to 2″ (4 to 5 cm). 2. deliver 12 breaths/minute. 3. perform only two-person CPR. 4. use the heel of one hand for sternal compressions.
4. use the heel of one hand for sternal compressions. RATIONALE: The nurse should use the heel of one hand and compress one-third to one-half the depth of the chest. The nurse should use the heels of both hands clasped together and compress the sternum 1½″ to 2″ for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12 breaths/minute.
A nurse is preparing to administer the first dose of tobramycin (Nebcin) to an adolescent with cystic fibrosis. The order is for 3 mg/kg I.V. daily in three divided doses. The client weighs 95 lb. How many milligrams should the nurse administer per dose? Record your answer using one decimal place. Answer: milligrams
43.2 milligrams RATIONALE: To perform this dosage calculation, the nurse should first convert the client's weight to kilograms using this formula: 1 kg/2.2 lb = X kg/95 lb 2.2X = 95 X = 43.2 kg Then, she should calculate the client's daily dose using this formula: 43.2 kg × 3 mg/kg = 129.6 mg Lastly, the nurse should calculate the divided dose: 129.6 mg ÷3 doses = 43.2 mg/dose
A nurse is preparing a dose of amoxicillin for a 3-year-old child with acute otitis media. The child weighs 33 lb. The dosage ordered is 50 mg/kg/day in divided doses every 8 hours. The concentration of the drug is 250 mg/5 ml. How many milliliters should the nurse administer? Record your answer using a whole number. Answer: milliliters
5 milliliters RATIONALE: To calculate the child's weight in kilograms, the nurse should use the following formula: 2.2 lb/1 kg = 33 lb/X kg X = 33 ÷ 2.2 X = 15 kg. Next, the nurse should calculate the daily dosage for the child: 50 mg/kg/day × 15 kg = 750 mg/day. To determine divided daily dosage, the nurse should know that "every 8 hours" means 3 times per day. So, she should perform that calculation in this way: Total daily dosage ÷ 3 times per day = Divided daily dosage 750 mg/day ÷ 3 = 250 mg The drug's concentration is 250 mg/5 ml, so nurse should administer 5 ml.
5. The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing clear liquid, in the antecubital area. Which is the most appropriate action by the nurse? a. Call security b. Call the police c. Call the nursing supervisor d. Lock the co-worker in the medication room until help is obtain
5. C- Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action.
45. The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have anticonvulsant medication serum levels checked regularly.
5. Do not drive alone; have someone in the car. 1. Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may trigger a seizure. 3. Over-the-counter medications may contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a seizure. 4. Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level.
6. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance obtaining a witness to the will. Which is the most appropriate response to the client? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own.' c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request."
6. D- Living wills, also known as natural death acts in some states, are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Laws and guidelines regarding living wills vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.
7. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? a. Documenting a late entry into the client's record b. Trying to erase the error for space to write in the correct data c. Using whiteout to delete the error to write in the correct data d. Drawing one line through the error, initialing and dating, and then documenting the correct information.
7. D- If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initializing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of whiteout are prohibited
8. Which identifies accurate nursing documentation notations? Select all that apply a. The client slept through the night b. Abdominal wound dressing is dry and intact without drainage c. The client seemed angry when awakened for vital sign measurement d. The client appears to become anxious when it is time for respiratory treatments e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema
8. A, B, E- Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears is not acceptable because these words suggest that the nurse is stating an opinion.
9. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that he or she cannot leave the hospital d. Observing care provided to the client without the client's permission
9. D- Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to a give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.
A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A. "My leg might turn very white after the surgery." B. "I should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."
A Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis
3. A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate? a. "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size." b. "Annual x-rays will increase your risk for cancer because of exposure to radiation." c. "Insurance companies do not authorize yearly x-rays just to detect early lung cancer." d. "Frequent x-rays damage the lungs and make them more susceptible to cancer."
A Rationale: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.
21. A 63-year-old patient is newly diagnosed with type 2 diabetes. When developing an education plan, the nurse's first action should be to a. assess the patient's perception of what it means to have type 2 diabetes. b. demonstrate how to check glucose using capillary blood glucose monitoring. c. ask the patient's family to participate in the diabetes education program. d. discuss the need for the patient to actively participate in diabetes management.
A Rationale: Before planning education, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. Cognitive Level: Application Text Reference: p.1264 Nursing Process: Planning NCLEX: Health Promotion and Maintenance
31. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action? a. The patient's visitors bring in some fresh peaches from home. b. The patient ambulates several times a day in the room. c. The patient uses soap and shampoo to shower every other day. d. The patient cleans with a warm washcloth after having a stool.
A Rationale: Fresh, thinned-skin peaches are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help to prevent perineal skin breakdown and infection.
34. When assessing a patient's needs for psychologic support after the patient has been diagnosed with stage I cancer of the colon, which question by the nurse will provide the most information? a. "Can you tell me what has been helpful to you in the past when coping with stressful events?" b. "How long ago were you diagnosed with this cancer?" c. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?" d. "How do you feel about having a possibly terminal illness?"
A Rationale: Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. The patient with stage I cancer is not considered to have a terminal illness at this time, and this question is likely to worry the patient unnecessarily.
14. A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.
A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. Intensive insulin therapy and an insulin pump are comparable in glucose control. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Implementation NCLEX: Physiological Integrity
28. Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.
A Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity
11. The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is, a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I will buy the 0.5-ml syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before I inject the insulin."
A Rationale: Rotating sites is no longer necessary because all insulin is now purified human insulin, and the risk for lipodystrophy is low. The other patient statements are accurate and indicate that no additional instruction is needed. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
16. When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to a. stop the infusion if swelling is observed at the site. b. infuse the medication over a short period. c. administer the chemotherapy through small-bore catheter. d. hold the medication unless a central venous line is available.
A Rationale: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication should generally be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.
22. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. b. fluid overload resulting from aggressive fluid replacement. c. the presence of hypovolemic shock related to osmotic diuresis. d. cardiovascular collapse resulting from the effects of hyperglycemia.
A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity
20. A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patient a. chooses a puncture site in the center of the finger pad. b. washes the puncture site using soap and water. c. says the result of 130 mg indicates good blood sugar control. d. hangs the arm down for a minute before puncturing the site.
A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective. Cognitive Level: Application Text Reference: p. 1270 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
27. A bone marrow transplant is being considered for treatment of a patient with acute leukemia that has not responded to chemotherapy. In discussing the treatment with the patient, the nurse explains that a. hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT). b. the transplant of the donated cells is painful because of the nerves in the tissue lining the bone. c. donor bone marrow cells are transplanted immediately after an infusion of chemotherapy. d. the transplant procedure takes place in a sterile operating room to minimize the risk for infection.
A Rationale: The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room required. The HSCT takes place 1 or 2 days after chemotherapy to prevent damage to the transplanted cells by the chemotherapy drugs.
17. When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says, a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." b. "If I overeat at a meal, I will still take just the usual dose of medication." c. "If I become ill, I may have to take insulin to control my blood sugar." d. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels."
A Rationale: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.
26. While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick. b. administer 1 mg glucagon subcutaneously. c. have the patient eat a candy bar. d. have the patient drink 4 ounces of orange juice.
A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity
16. Glyburide (Micronase, DiaBeta, Glynase) is prescribed for a patient whose type 2 diabetes has not been controlled with diet and exercise. When teaching the patient about glyburide, the nurse explains that a. glyburide stimulates insulin production and release from the pancreas. b. the patient should not take glyburide for 48 hours after receiving IV contrast media. c. glyburide should be taken even when the blood glucose level is low in the morning. d. glyburide decreases glucagon secretion.
A Rationale: The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, since hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contract, but this is not necessary for glyburide. Cognitive Level: Application Text Reference: pp. 1265-1266 Nursing Process: Implementation NCLEX: Physiological Integrity
22. A 40-year-old divorced mother of four school-age children is hospitalized with metastatic cancer of the ovary. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. The most appropriate response by the nurse is a. "Why don't we talk about the options you have for the care of your children?" b. "Many patients with cancer live for a long time, so there is time to plan for your children." c. "For now you need to concentrate on getting well, not worry about your children." d. "Perhaps your ex-husband will take the children when you can't care for them."
A Rationale: This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans.
32. Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.
A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics. Cognitive Level: Application Text Reference: p. 1285 Nursing Process: Implementation NCLEX: Physiological Integrity
32. Which action by a nursing assistant (NA) when caring for a patient who is pancytopenic indicates a need for the nurse to intervene? a. The NA assists the patient to use dental floss after eating. b. The NA makes an oral rinse using 1 teaspoon of salt in a liter of water. c. The NA adds baking soda to the patient's saline oral rinses. d. The NA puts fluoride toothpaste on the patient's toothbrush.
A Rationale: Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient.
A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? a. prevent patient infection. b. avoid abnormal bleeding. c. give pneumococcal vaccine. d. provide companionship while isolated.
A - After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done, but should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.
Which statement by the patient with type 2 diabetes is accurate? a. "I am supposed to have a meal or snack if I drink alcohol." b. "I am not allowed to eat any sweets because of my diabetes." c. "I do not need to watch what I eat because my diabetes is not the bad kind." d. "The amount of fat in my diet is not important. Only carbohydrates raise my blood sugar."
A - Alcohol should be consumed with food to reduce the risk of hypoglycemia.
When assessing a patient's nutritional-metabolic pattern related to hematologic health, what should the nurse do? a. inspect the skin for petechiae. b. ask the patient about joint pain. c. assess for vitamin C deficiency. d. determine if the patient can perform ADLs
A - Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. The other options are not specific to the nutritional-metabolic pattern related to hematologic health.
The nurse is assigned to the care of a 64-year-old patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention? a. assess patient's perception of what it means to have diabetes. b. ask the patient to write down current knowledge about diabetes. c. set goals for the patient to actively participate in managing his diabetes. d. assume responsibility for all of the patient's care to decrease stress level.
A - In order for teaching to be effective, the first step is to assess the patient. Teaching can be individualized once the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.
Significant information obtained from the patient's health history that relates to the hematologic system includes: a. jaundice b. bladder surgery c. early menopause d. multiple pregnancies
A - Jaundice is a common symptom that occurs with hematologic abnormalities. Jaundice is related to an accumulation of bile pigment that is caused by rapid or excessive hemolysis or liver damage.
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a. A1C 9% b. BP 126/80 mm Hg c. FBG 130 mg/dL (7.2 mmol/L) d. LDL cholesterol 100 mg/dL (2.6 mmol/L)
A - Lowering hemoglobin A1C (to less than 7%) reduces microvascular and neuropathic complications. Tighter glycemic control (normal hemoglobin A1C level, less than 6%) may further reduce complications but increases hypoglycemia risk.
Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? a. increased triglyceride levels b. increased high-density lipoproteins (HDL) c. decreased low-density lipoproteins (LDL) d. decreased very-low-density lipoproteins (VLDL)
A - Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.
The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient? a. multiple myeloma b. thrombocytopenia c. megaloblastic anemia d. myelodysplastic syndrome
A - Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.
In a severely anemic patient, the nurse would expect to find: a. dyspnea and tachycardia b. cyanosis and pulmonary edema c. cardiomegaly and pulmonary fibrosis d. ventricular dysrhythmias and wheezing
A - Patients with severe anemia (hemoglobin level, less than 6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction, tachypnea, orthopnea, and dyspnea at rest.
When caring for a patient with thrombocytopenia, the nurse instructs the patient to: a. dab his or her nose instead of blowing b. be careful when shaving with a safety razor c. continue with physical activities to stimulate thrombopoiesis d. avoid Aspirin (ASA) because it may mask the fever that occurs with thrombocytopenia
A - Patients with thrombocytopenia should avoid aspirin because it reduces platelet adhesiveness, which contributes to bleeding. Patients should not perform vigorous exercise or lift weights. If a patient is weak and at risk for falling, supervise the patient when he or she is out of bed. Blowing the nose forcefully should be avoided. The patient should gently pat the nose with a tissue if needed. Instruct patients not to shave with a blade; an electric razor should be used.
In assessing the patient, which abnormal finding should the nurse relate to hemostasis abnormalities? a. purpura b. pruritus c. weakness d. pale conjunctiva
A - Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis, but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low Hgb level.
The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. elevated D-dimers b. elevated fibrinogen c. reduced prothrombin time (PT) d. reduced fibrin degradation products (FDPs)
A - The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.
The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes? a. excessive thirst b. gradual weight gain c. overwhelming fatigue d. recurrent blurred vision
A - The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.
The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product? a. infuse the fresh frozen plasma as rapidly as the patient will tolerate. b. hang the fresh frozen plasma as a piggyback to the primary IV solution. c. infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. d. hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.
A - The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in Factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.
The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? a. chooses a puncture site in the center of the finger pad. b. washes hands with soap and water to cleanse the site to be used. c. warms the finger before puncturing the finger to obtain a drop of blood. d. tells the nurse that the result of 110 mg/dL indicates good control of diabetes.
A - The patient should select a site on the sides of the fingertips, not on the center of the finger pad as this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.
Before beginning a transfusion of RBCs, which action by the nurse would be of highest priority to avoid an error during this procedure? a. check the identifying information on the unit of blood against the patient's ID bracelet. b. select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion. c. remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. d. add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.
A - The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.
The public health nurse is providing follow-up care to a client with TB who does not regularly take his medication. Which nursing action would be most appropriate for this client? A Ask the client's spouse to supervise the daily administration of the medications. B Visit the clinic weekly to ask him whether he is taking his medications regularly. C Notify the physician of the client's non-compliance and request a different prescription. D Remind the client that TB can be fatal if not taken properly.
A) Question 59 Explanation: Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment.
A client with a productive cough, chills, and night sweats is suspected of having active TB. The physician should take which of the following actions? A Admit him to the hospital in respiratory isolation B Prescribe isoniazid and tell him to go home and rest C Give a tuberculin test and tell him to come back in 48 hours and have it read D Give a prescription for isoniazid, 300 mg daily for 2 weeks, and send him home
A) The client is showing s/s of active TB and, because of the productive cough, is highly contagious. He should be admitted to the hospital, placed in respiratory isolation, and three sputum cultures should be obtained to confirm the diagnosis. He would most likely be given isoniazid and two or three other antitubercular antibiotics until the diagnosis is confirmed, then isolation and treatment would continue if the cultures were positive for TB. After 7 to 10 days, three more consecutive sputum cultures will be obtained. If they're negative, he would be considered non-contagious and may be sent home, although he'll continue to take the antitubercular drugs for 9 to 12 months.
The nurse obtains a sputum specimen from a client with suspected TB for laboratory study. Which of the following laboratory techniques is most commonly used to identify tubercle bacilli in sputum? A Acid-fast staining B Sensitivity testing C Agglutination testing D Dark-field illumination
A) The most commonly used technique to identify tubercle bacilli is acid-fast staining. The bacilli have a waxy surface, which makes them difficult to stain in the lab. However, once they are stained, the stain is resistant to removal, even with acids. Therefore, tubercle bacilli are often called acid-fast bacilli.
A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: A Positive B Negative C Inconclusive D The need for repeat testing
A) The client with HIV+ status is considered to have positive results on PPD skin test with an area greater than 5-mm of induration. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client.
A client admitted with angina compains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first? A) Activate the resuscitation team B) Open the client's airway C) Check for breathing D) Check for signs of circulation
A) Activate the resuscitation team Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing (looking, listening, and feeling for no more than 10-seconds). If the client isn't breathing, give two slow breaths using a bag mask or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.
Which of the following terms describes the force against which the ventricle must expel blood? A) Afterload B) Cardiac output C) Overload D) Preload
A) Afterload Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled by the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole.
Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? A) Beta-adrenergic blockers B) Calcium channel blockers C) Narcotics D) Nitrates
A) Beta-adrenergic blockers Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).
The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following? A) Obtaining an infusion pump for the medication B) Monitoring BP q4h C) Monitoring urine output hourly D) Obtaining serum potassium levels daily
A) Obtaining an infusion pump for the medication IV nitro infusion requires an infusion pump for precise control of the medication. BP monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
Which of the following interventions should be the first priority when treating a client experiencing chest pain while walking? A) Sit the client down B) Get the client back to bed C) Obtain an ECG D) Administer sublingual nitroglycerin
A) Sit the client down The initial priority is to decrease the oxygen consumption; this would be achieved by sitting the client down. An ECG can be obtained after the client is sitting down. After the ECGm sublingual nitro would be administered. When the client's condition is stabilized, he can be returned to bed.
Which of the following complications is indicated by a third heart sound (S3)? A) Ventricular dilation B) Systemic hypertension C) Aortic valve malfunction D) Increased atrial contractions
A) Ventricular dilation Rapid filling of the ventricle causes vasodilation that is auscultated as S3. Increased atrial contraction or systemic hypertension can result in a fourth heart sound. Aortic valve malfunction is heard as a murmur
Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (select all that apply): a. monitoring stools for guaiac b. instructions for high-iron diet c. taking vital signs every 8 hours d. teaching self-injection of erythropoietin e. administration of cobalamin (vitamin B12) injections
A, B - Stool guaiac test is performed to determine the cause of iron-deficiency anemia that is related to gastrointestinal bleeding. Iron is increased in the diet. Teach the patient which foods are good sources of iron. If nutrition is already adequate, increasing iron intake by dietary means may not be practical. The patient with iron deficiency related to acute blood loss may require a transfusion of packed red blood cells (RBCs).
The nursing management of a patient in sickle cell crisis incudes (select all that apply): a. monitoring CBC b. optimal pain management and O2 therapy c. blood transfusions if required and iron chelation d. rest as needed and deep vein thrombosis prophylaxis e. administration of IV iron and diet high in iron content
A, B, C, D - Complete blood count (CBC) is monitored. Infections are common with elevated white blood cell counts, and anemia may occur with low hemoglobin levels and low RBC counts. Oxygen may be administered to treat hypoxia and control sickling. Rest may be instituted to reduce metabolic requirements, and prophylaxis for deep vein thrombosis (with anticoagulants) is prescribed. Transfusion therapy is indicated when an aplastic crisis occurs. Patients may require iron chelation therapy to reduce transfusion-produced iron overload. Pain occurring during an acute crisis is usually undertreated; patients should have optimal pain control with opioid analgesics, nonsteroidal antiinflammatory agents, antineuropathic pain medications, local anesthetics, or nerve blocks.
Priority nursing actions when caring for a hospitalized patient with a new onset temperature of 102.2 F and severe neutropenia include (select all that apply): a. administering the prescribed antibiotic STAT b. drawing peripheral and central line blood cultures c. ongoing monitoring of the patient's vital signs for septic shock d. taking a full set of vital signs and notifying the physician immediately e. administering transfusions of WBCs treated to decrease immunogenicity
A, B, C, D - Early identification of an infective organism is a priority, and cultures should be obtained from various sites. Serial blood cultures (at least two) or one from a peripheral site and one from a venous access device should be obtained promptly. In a febrile neutropenic patient, antibiotics should be started immediately (within 1 hour). Cultures of the nose, throat, sputum, urine, stool, obvious lesions, and blood may be indicated. Ongoing febrile episodes or a change in the patient's assessment findings (or vital signs) necessitates a call to the physician for additional cultures, diagnostic tests, addition of antimicrobial therapies, or a combination of these.
A client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? (Select all that apply.) A. Brain B. Bone C. Lymph nodes D. Kidneys E. Liver
A, B, C, E Typical sites of metastasis of lung cancer include the brain, bone, liver, lymph nodes, and pancreas. Kidneys are not a typical site of lung cancer metastasis.
The nurse educates a primary HTN patient on lifestyle changes. Which ones should be included in her teaching? A. consume more fruits/veggies B. Monitor/lose weight C. Limit alchoholic drinks to 3 per day or less D. Regular exercise (walking) E. Limit sodium intake to 3200 mg per day
A, B, D
The nurse includes which factors in teaching regarding the typical warning signs of cancer? (Select all that apply.) A. Persistent constipation B. Scab present for 6 months C. Curdlike vaginal discharge D. Axillary swelling E. Headache
A, B, D Change in bowel habits, a sore that does not heal, and a lump or thickening in the breast or elsewhere are all potential warning signs of cancer. Curdlike vaginal discharge represents a yeast infection. Headache is not a warning sign, but may be present with multiple problems.
When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? (Select all that apply.) Neuro: Episodes of confusion Cardiac: Pulse 88 and regular Musculoskeletal: Weakness, tremor Na: 115, K: 4.2, Creatinine: 0.8 ondansetron (Zofran) cyclophosphamide (Cytoxan) A. Hyponatremia B. Mental status changes C. Azotemia D. Bradycardia E. Weakness
A, B, E Antidiuretic hormone (ADH) is secreted or produced ectopically, resulting in water retention and sodium dilution. Dilutional hyponatremia results from ADH secretion, causing confusion and changes in mental status. Weakness results from hyponatremia. Azotemia refers to buildup of nitrogenous waste products in the blood, typically from renal damage. Bradycardia is not part of the constellation of symptoms related to SIADH; tachycardia may result from fluid volume excess.
The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine
A, B, E Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.
A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply)? a. the level may be increased as a result of dehydration that accompanies hyperglycemia. b. the patient may be excreting extra sodium and retaining potassium because of malnutrition. c. the level is consistent with renal insufficiency that can develop with renal nephropathy. d. the level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. e. this level demonstrates adequate treatment of the cellulitis and effective serum glucose control.
A, C, D - The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. Kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis since potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. The elevated potassium level does not demonstrate adequate treatment of cellulitis or effective serum glucose control.
Nursing care for a patient immediately after a bone marrow biopsy and aspiration includes (select all that apply): a. administering analgesics as necessary b. preparing to administer a blood transfusion c. instructing on need to lie still with a sterile pressure dressing intact d. monitoring vital signs and assessing the site for excess drainage or bleeding e. instructing on the need for preprocedure and post procedure antibiotic medications
A, C, D - The needle aspiration or biopsy site is covered with a sterile pressure dressing. Monitor the patient's vital signs until stable, and assess the site for excess drainage or bleeding. If bleeding is detected, advise the patient to lie on the side for 30 to 60 minutes to maintain pressure on the site. If the bed is too soft, have the patient lie on a rolled towel to provide additional pressure. Analgesics for post procedure pain may be administered. Soreness over the puncture site for 3 to 4 days after the procedure is normal.
Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply.) A. Fatigue B. Changes in color of hair C. Change in taste D. Changes in skin of the neck E. Difficulty swallowing
A, C, D, E Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific; the larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.
The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) A. Assess for fever. B. Observe for bleeding. C. Administer pegfilgrastim (Neulasta) - a biologic response modifier D. Do not permit fresh flowers or plants in the room. E. Do not allow the client's 16-year-old son to visit. F. Teach the client to omit raw fruits and vegetables from the diet.
A, C, D, F Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well; however, very small children, who may get frequent colds and viral infections, may pose a risk.
Which are appropriate therapies for patients with diabetes mellitus (select all that apply)? a. use of statins to treat dyslipidemia b. use of diuretics to treat nephropathy c. use of ACE inhibitors to treat nephropathy d. use of serotonin agonists to decrease appetite e. use of laser photocoagulation to treat retinopathy
A, C, E - In patients with diabetes who have microalbuminuria or macroalbuminuria, angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (ARBs) (e.g., losartan [Cozaar]) should be used. Both classes of drugs are used to treat hypertension and have been found to delay the progression of nephropathy in patients with diabetes. The statin drugs are the most widely used lipid-lowering agents. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy, in those with macular edema, and in some cases of nonproliferative retinopathy.
You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? (select all that apply) a. insulin administration b. elimination of sugar from diet c. need to reduce physical activity d. use of a portable blood glucose monitor
A, D, E - The nurse ensures that the patient understands the proper use of insulin. The nurse teaches the patient how to use the portable blood glucose monitor and how to recognize and treat signs and symptoms of hypoglycemia and hyperglycemia.
The patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about (select all that apply)? a. strict hand washing b. daily nasal swabs for culture c. monitor temperature every hour. d. daily skin care and oral hygiene e. encourage eating all foods to increase nutrients. f. private room with a high-efficiency particulate air (HEPA) filter
A, D, F - Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora, other people, and uncooked meats, seafood, eggs, unwashed fruits and vegetables, and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.
When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."
A. "I will need to isolate any tissues I use so as not to infect my family." HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat.
The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? A. "My mother and grandmother had breast cancer, so I am at risk." B. "I get a mammogram every 2 years since I turned 30." C. "A clinical breast examination is performed every month since I turned 40." D. "A computed tomography (CT) scan will be done every year after I turn 50."
A. "My mother and grandmother had breast cancer, so I am at risk." A strong family history of breast cancer indicates a risk for breast cancer. Annual rather than biannual screening may be indicated for a strong family history. An annual mammogram is performed after age 40 or in younger clients with a strong family history. The client may perform a self-breast examination monthly; a clinical examination by a health care provider is indicated annually. Annual CT breast scans after age 50 are not a current recommendation.
Which information must the organ transplant nurse emphasize before a client is discharged? A. "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." B. "You are at increased risk for cancer when you reach 60 years of age." C. "Immunosuppressant medications will decrease your risk for developing cancers." D. "After 6 months, you may stop immunosuppressant medications, and your risk for cancer will be the same as that of the general population."
A. "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." Use of immunosuppressant medications to prevent organ rejection increases the risk for cancer. Advanced age is a risk factor for all people, not just for organ transplant recipients. Immunosuppressant medications must be taken for the life of the organ; the risk for developing cancer remains.
A nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus? (Select all that apply.) A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure
A. CORRECT: Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take cautionary measures to prevent HIV exposure. B. INCORRECT: Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. C. INCORRECT: Having a monogamous sex partner is not a risk factor associated with the HIV virus. D. CORRECT: Being an older adult woman is a risk factor associated with the HIV virus due vaginal dryness and the thinning of the vaginal wall. E. CORRECT: Occupational exposure, such as being a health care worker, is a risk factor associated with the HIV virus.
A nurse is caring for a client who is suspected of having HIV. Which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. CD4+ T-lymphocyte percentage of total lymphocytes E. Cerebrospinal fluid (CSF) analysis
A. CORRECT: Positive results of a Western blot test confirm the presence of HIV infection. B. CORRECT: Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection. C. INCORRECT: CD4+ T-lymphocyte count assists with classifying the stage of HIV infection. D. INCORRECT: CD4+ T-lymphocyte percentage of total lymphocytes assists with classifying the stage of HIV infection. E. INCORRECT: CSF analysis can be used to confirm meningitis.
A nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when current symptoms began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.
A. CORRECT: The nurse should perform a physical assessment to gather data about the client's condition. This is an appropriate action by the nurse. B. CORRECT: The nurse should gather more data to determine whether the clinical manifestations are acute or chronic. This is an appropriate action by the nurse. C. INCORRECT: Teaching the client about HIV transmission is not an appropriate action by the nurse at this time. This is not a priority action for the nurse to include at this time. D. INCORRECT: Drawing blood for HIV testing is not an appropriate action by nurse at this time. This is not a priority action for the nurse to include at this time. E. CORRECT: The nurse should obtain a sexual history to determine how the virus was transmitted. This is an appropriate action by the nurse.
The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast
A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people; the nurse should see the client with chemotherapy-induced neutropenia first. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.
The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities
A. Delaying disease progression These health promotion activities along with mental health counseling, support groups, and a therapeutic relationship with health care providers will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities
The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A. Hemoglobin of 7.4 and hematocrit of 21.8 B. Potassium level of 2.9 mEq/L and diarrhea C. 250,000 platelets/mm3 D. 5000 white blood cells/mm3
A. Hemoglobin of 7.4 and hematocrit of 21.8 Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.
A nurse is completing discharge instructions with a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."
A. INCORRECT: A client who has AIDS should avoid changing the pet litter box to prevent acquiring toxoplasmosis. B. INCORRECT: A client who has AIDS should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. C. INCORRECT: Due to compromised immune response, a client who has AIDS should avoid contact with family members who are ill. D. CORRECT: A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections.
The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A. Monitor weight B. Trend red blood cells and hemoglobin and hematocrit C. Monitor platelets D. Observe for motor deficits
A. Monitor weight Cachexia results in extreme body wasting and malnutrition; severe weight loss is expected. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.
When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? A. Tobacco use B. Ethnicity C. Gender D. Increased age
A. Tobacco use Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can change. Ethnicity, gender, and increasing age are associated with lung cancer, but they are not modifiable risks.
A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient? a. "The EIA test will need to be repeated to verify the results." b. "A viral culture will be done to determine the progression of the disease." c. "It will probably be 10 or more years before you develop acquired immunodeficiency syndrome (AIDS)." d. "The Western blot test will be done to determine whether acquired immunodeficiency syndrome (AIDS) has developed."
ANS: A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not usually part of HIV testing. It is not appropriate for the nurse to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.
A patient is diagnosed with hypertension and nadolol (Corgard) is prescribed. The nurse should consult with the health care provider before giving this medication upon finding a history of a. asthma. b. peptic ulcer disease. c. alcohol dependency. d. myocardial infarction (MI).
ANS: A Nonselective β-blockers block β1- and β2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. β-blockers will have no effect on the patient's peptic ulcer disease or alcohol dependency. β-blocker therapy is recommended after MI.
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure
ANS: A Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.
Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Have the patient record dietary intake for 3 days. b. Give the patient a detailed list of low-sodium foods. c. Teach the patient about foods that are high in sodium. d. Help the patient make an appointment with a dietitian.
ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary. The other actions may be appropriate, but assessment of the patient's baseline should occur first.
An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching? a. Many medications have interactions with antiretroviral drugs. b. Less frequent CD4+ level monitoring is needed in older adults. c. Hospice care is available for patients with terminal HIV infection. d. Progression of HIV infection occurs more rapidly in older patients.
ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient with asymptomatic HIV infection is not a candidate for hospice. Progression of HIV is not affected by age, although it may be affected by chronic disease
The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin
ANS: A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.
Which assessment finding for a patient who is receiving furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 180 mg/dL b. Blood potassium level of 3.0 mEq/L c. Early morning BP reading of 164/96 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg
ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.
A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART).
ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use."
ANS: B Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs
The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 52-year-old with a BP of 212/90 who has intermittent claudication b. 43-year-old with a BP of 190/102 who is complaining of chest pain c. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria
ANS: B The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.
ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.
A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.
ANS: C After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.
A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan? a. Driving is allowed when starting this medication. b. Report any bizarre dreams to the health care provider. c. Continue to use contraception while on this medication. d. Take this medication in the morning on an empty stomach.
ANS: C Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The drug should not be used during pregnancy because large doses could cause fetal anomalies. Once-a-day doses should be taken at bedtime (at least initially) to help patients cope with the side effects that include dizziness and confusion. Patients should be cautioned about driving when starting this drug. Patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium nitroprusside (Nipride) to treat a hypertensive emergency? a. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. b. Assist the patient up in the chair for meals to avoid complications associated with immobility. c. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements. d. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.
ANS: C Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.
A patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? a. Schedule the patient for frequent BP checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Tell the patient how to self-monitor and record BPs at home. d. Teach the patient about ambulatory blood pressure monitoring.
ANS: C Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Frequent BP checks in the clinic are likely to be high in a patient with white coat hypertension. Ambulatory blood pressure monitoring may be used if the data from self-monitoring is unclear. Although elevated stress levels may contribute to hypertension, instructing the patient about this is unlikely to reduce BP.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions
ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and has a BP of 240/118 mm Hg. Which question should the nurse ask first? a. Did you take any acetaminophen (Tylenol) today? b. Do you have any recent stressful events in your life? c. Have you been consistently taking your medications? d. Have you recently taken any antihistamine medications?
ANS: C Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
The charge nurse observes a new RN doing discharge teaching for a hypertensive patient who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. check the BP with a home BP monitor every day. b. move slowly when moving from lying to standing. c. increase the dietary intake of high-potassium foods. d. make an appointment with the dietitian for teaching.
ANS: C The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.
During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's most recent BP reading is 156/94 mm Hg. b. The patient's pulse has dropped from 64 to 58 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.
ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.
Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose latest CD4+ count is 250/µL b. Patient whose rapid HIV-antibody test is positive c. Patient who has had 10 liquid stools in the last 24 hours d. Patient who has nausea from prescribed antiretroviral drugs
ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock
Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Obtain a BP reading in each arm and average the results. b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. c. Have the patient sit in a chair with the feet flat on the floor. d. Assist the patient to the supine position for BP measurements.
ANS: C The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.
The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which patient statement indicates that more teaching is needed? a. "The medication may not work as well if I take any aspirin." b. "The doctor may order a blood potassium level occasionally." c. "I will call the doctor if I notice that I have a frequent cough." d. "I won't worry if I have a little swelling around my lips and face."
ANS: D Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.
The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient's blood glucose level is 142 mg/dL. b. The patient complains of feeling "constantly tired." c. The patient is unable to state the side effects of the medications. d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)."
ANS: D Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT.
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a. Patient who is currently HIV negative but has unprotected sex with multiple partners b. Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µL c. HIV-positive patient with a CD4+ count of 160/µL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
ANS: D CMV retinitis is an acquired immunodeficiency syndrome (AIDS)-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patient's social support system c. Potential medication side effects d. Patient's ability to comply with ART schedule
ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? a. "Thinking about dying will not improve the course of AIDS." b. "It is important to focus on the good things about your life now." c. "Do you think that taking an antidepressant might be helpful to you?" d. "Can you tell me more about the kind of thoughts that you are having?"
ANS: D More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings.
When a patient with hypertension who has a new prescription for atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit, the BP is unchanged from the previous visit. Which action should the nurse take first? a. Provide information about the use of multiple drugs to treat hypertension. b. Teach the patient about the reasons for a possible change in drug therapy. c. Remind the patient that lifestyle changes also are important in BP control. d. Question the patient about whether the medication is actually being taken.
ANS: D Since noncompliance with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient compliance with the prescribed therapy.
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of dietary protein. c. The patient has only one cup of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.
ANS: D The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.
A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient? a. Check BP daily before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.
ANS: D The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the drugs should be taken.
ANS: D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.
ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection.
Which of the following is correct about the rate of cell growth in relation to chemotherapy? A. Faster growing cells are less susceptible to chemotherapy B. Non dividing cells are more susceptible to chemotherapy C. Faster growing cells are more susceptible to chemotherapy D. Slower growing cells are more susceptible to chemotherapy
ANSWER C The faster the cell grows the more susceptible it is to chemotherapy,
The nurse should be aware of contraindications be aware of what adverse reactions the burse should be aware of contraindications in what client
Acute bronchial asthma head injuries in grand mal seizures
What do the islets of Langerhans house?
Alpha cells Beta cells Delta cells
What is an alternative to daily insulin injections
An Insulin infusion pump
After teaching a group of nursing students about opioid antagonistThe teacher determines and understanding from the students when the students identify which of the following to be true
And opioid antagonist has greater affinity to be opioid receptors opioid antagonist prevents the response from opioid agonist by binding to opioid receptor down
3) A nurse is instructing a client how to decrease nausea secondary to chemotherapy and radiation. The nurse understands that the client needs more teaching if the client states, "I will try A. eating small, frequent meals" B. Staying upright for at least on hour during meals" C. Avoiding a lot of liquids with my meals" D. Increasing the amount of unsaturated fats in my diet"
Answer - D - increasing the amount of unsaturated fats in my diet"
Which statement is correct about the rate of cell growth in relation to chemotherapy? 1. Faster growing cells are less susceptible to chemotherapy. 2. Nondividing cells are more susceptible to chemotherapy. 3. Faster growing cells are more susceptible to chemotherapy. 4. Slower growing cells are more susceptible to chemotherapy.
Answer 3 The faster the cell grows, the more susceptible it is to chemotherapy and radiation therapy. Slow-growing and nondividing cells are less susceptible to chemotherapy. Repeated cycles of chemotherapy are used to destroy nondividing cells as the begin active cell division.
During the administration of a chemotherapeutic drug, the nurse observes that there is a lack of blood return from the intravenous catheter. The priority action by the nurse would be to A. stop the administration of the drug immediately B. reposition the client's arm and continue with the administration of the drug C. apply a tourniquet to the patient's affected arm and notify the doctor D. continue to administer the drug and assess for edema at the IV site
Answer A Chemotherapeutic agents are irritating to tissues. Lack of blood return from the IV catheter indicates that it is out of vein. Therefore, administration of the drug should be stopped immediately
A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? "a. Sexual dysfunction related to radiation therapy b. Anticipatory grieving related to terminal illness c. Tissue integrity related to prolonged bed rest d. Fatigue related to chemotherapy
Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin's disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority
The mother of a child diagnosed with a potentially life-threatening form of cancer says to the nurse, ""I don't understand how this could happen to us. We have been so careful to make sure our child is healthy."" Which response by the nurse is most appropriate? A. "Why do you say that? Do you think that you could have prevented this?" B. "This must be a difficult time for you and your family. Would you like to talk about how you are feeling?" C. "You shouldn't feel that you could have prevented the cancer. It is not your fault." D."Many children are diagnosed with cancer. It is not always life-threatening.""
Answer B Parents of children diagnosed with cancer require major emotional support, and should be allowed to express their feelings. Prevention and blaming oneself is not supportive, nor is telling the parents that there are many other children with cancer.
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives? a. Weight gain should be reported to the physician. b. An alternate method of birth control is needed when taking antibiotics. c. If the client misses one or more pills, two pills should be taken per day for 1 week. d. Changes in the menstrual flow should be reported to the physician.
Answer B is correct. When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5-10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.
A nurse is teaching a group of women about the appropriate method for performing a breast self-exam (BSE). Which of the following statements regarding breast self-exam demonstrates correct comprehension of the material? A. "Breast exams should begin around age 30." B. "Breast exams should be done one week prior to the menstrual cycle." C. "Breast exams should incorporate both feeling and looking at the breasts." D. "Breast exams should be done during the middle of the menstrual cycle."
Answer C Rationale: Breast exams should incorporate both feeling and looking at the breasts. Premenstrual swelling and tenderness of the breasts may be present one week prior. Breast self-examination should begin as early as possible, preferably when the individual is an adolescent.
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment? a. The client collects stamps as a hobby. b. The client recently lost his job as a postal worker. c. The client had radiation for treatment of Hodgkin's disease as a teenager. d. The client's brother had leukemia as a child.
Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: a. Her contractions are 2 minutes apart. b. She has back pain and a bloody discharge. c. She experiences abdominal pain and frequent urination. d. Her contractions are 5 minutes apart.
Answer D is correct. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? a. Painless vaginal bleeding b. Abdominal cramping c. Throbbing pain in the upper quadrant d. Sudden, stabbing pain in the lower quadrant
Answer D is correct. The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers A, B, and C incorrect.
6). A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium levels 5. Decreased oral sodium intake 6. Medication that is antagonistic to antidiuretic hormone
Answer: 1,2,4,6 Rational: Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.
8). A nurse is teaching a client who is receiving radiation treatment for left lower lobe lung cancer. Which client statement indicates a need for further treatment? 1. "I'll use hats to protect my head from the sun when my hair falls out" 2. "If I get nauseous, I'll try to eat several small, bland meals each day" 3. "I'll allow myself plenty of time to rest between activities" 4. "Most of the adverse effects should go away shortly after my last radiation treatment"
Answer: 1-"I'll use hats to protect my head from the sun when my hair falls out" Rational: The client requires additional teaching if he mentions that he will lose the hair on his head a result of radiation therapy. Alopecia as an acute, localized adverse effect of radiation. The treatment area for this client's cancer will be localized to the lower aspects of his lungs, not his head. Nausea and fatigue are expected generalized adverse effects of radiation therapy. Most adverse effects of radiation are temporary and will stop when treatment is complete.
2). The client is 4 hours post-lobectomy for lung cancer. Which assessment data warrants immediate intervention by the nurse? 1. Intake of 1500 mL IV and output of 1000 mL. 2. 450 mL of bright red drainage in the chest tube. 3. Complaining of pain at a 10 on a 1-10 scale. 4. Absent lung sound on the side of surgery.
Answer: 2- 450 mL of bright red drainage in the chest tube. Rational: This is about a pint of blood and could indicate a hemorrhage. HINT: Blood is always a priority.
10). Which of the following is the primary goal for surgical resection of lung cancer? 1. To remove the tumor and all surrounding tissue 2. To remove the tumor and as little surrounding tissue as possible 3. To remove the entire tumor and any collapsed alveoli in the same region 4. To remove as much of the tumor as possible, without removing any alveoli
Answer: 2- To remove the tumor and as little surrounding tissue as possible Rational: The goal of surgical resection is to remove the lung tissue that has a tumor in it while saving as much surrounding tissue as possible. It may be necessary to remove alveoli and bronchioles, but care is taken to make sure only what's absolutely necessary is removed.
7). A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis? 1. A seizure disorder 2. Chronic obstructive pulmonary disease (COPD) 3. Anemia 4. A bleeding disorder
Answer: 4- A bleeding disorder Rational: A bleeding disorder is a contraindication for thoracentesis because a hemorrhage may occur during or after this procedure, possibly causing death. Although a history of a seizure disorder, COPD, or anemia calls for caution, it doesn't contraindicate thoracentesis.
4). A 69-year-old patient was diagnosed with lung cancer. He is receiving chemotherapy and the nurse caring for him reviewed the laboratory results showing a platelet count is 18,000/mm3 and a pH of 7.36. Which of the following measures would the nurse implement based on the laboratory result? 1. Contact isolation 2. Reverse isolation 3. Respiratory isolation 4. Bleeding precautions
Answer: 4- Bleeding precautions Rational: Normal platelet count is 150,000-400,000/mm3. Bleeding precautions should be implemented with a platelet count below 50,000/mm3. Patients receiving chemotherapy are at risk for thrombocytopenia. Bleeding precautions include avoiding anticoagulant and antiplatelet medications, using an electric razor, stool softeners to prevent straining, and avoiding dental floss.
5). A 71-year-old patient diagnosed with lung cancer is receiving chemotherapy on an outpatient basis. The nurse must provide which of the following home care instructions to the patient? 1. During chemotherapy, use disposable plates and plastic utensils 2. All members of the family can share a bathroom 3. Do not consider urine and stool as contaminated 4. If necessary, contaminated linens should be washed separately and then washed a second time with other laundry.
Answer: 4- If necessary, contaminated linens should be washed separately and then washed a second time with other laundry. Rational: Any contaminated linen or clothing should be washed separately and then washed a second time with other laundry to prevent exposure to chemotherapy in body fluids.
The nurse is caring for a young woman who is dying from breast cancer. The nurse determines that a defining characteristic of anticipatory grieving is present when the young woman: A. Discusses thoughts and feelings related to the loss. B. Has prolonged emotional reactions and outbursts. C. Verbalizes unrealistic goals and plans for the future. D. Ignores untreated medical conditions that require treatment.
Answer: A Rationale: The nurse can determine the client's stage of grief by observing the client's behavior. This is important because the appropriate nursing diagnoses must be developed so that the plan of care is appropriate.
For a female client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client? A. "Client verbalizes feelings of anxiety." B. "Client doesn't guess at prognosis." C. "Client uses any effective method to reduce tension." D. "Client stops seeking information."
Answer: A Rationale: Verbalizing feelings are the client's first step in coping with the situational crisis. It also helps the health care team gain insight into the client's feelings, helping guide psychosocial care. Suppressing speculation may prevent the client from coming to terms with the crisis and planning accordingly. Some methods of reducing tension, such as illicit drug or alcohol use, may prevent the client from coming to terms with the threat of death as well as cause physiologic harm. Seeking information can help a client with cancer gain a sense of control over the crisis
4) The nurse is developing a plan of care for a client being admitted to the hospital who is immunosuppressed and will be placed on neutropenic precautions. With regard to neutropenic precautions, which intervention is incorrect? A) admitting the client to a semi-private room B) placing a precaution sign on the door to the room C) placing a mask on the client if the client leaves the room D) removing a vase with fresh flowers left by a previous client
Answer: A - admitting the client to a semiprivate room
What nursing diagnosis is seen with acute lymphocytic leukemia and thrombocytopenia? A. potential for injury B. self-care deficit C. potential for self harm D. alteration in comfort
Answer: A potential for injury Low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage.
The husband of a client with cervical cancer says to the nurse, "The doctor told my wife that her cancer is curable. Is he just trying to make us feel better?" Which would be the nurse's most accurate response? A. "When cervical cancer is detected early and treated aggressively, the cure rate is almost 100%" B. "The 5-year survival rate is about 75%, which makes the odds pretty good." C. "Saying a cancer is curable means that 50% of all women with the cancer survive at least 5 years." D. "Cancers of the female reproductive tract tend to be slow-growing and respond well to treatment."
Answer: A. "When cervical cancer is detected early and treated aggressively , the cure rate is almost 100%" Rationale: When cervical cancer is detected early and treated aggressively, the cure rate approaches 100%. The incidence of cervical cancer has increased among African Americans, Native Americans, and Latinas, and these women often have a poorer prognosis because the cancer is not identified early. Papanicolaou (Pap) smears and colposcopy have the potential to decrease mortality from invasive carcinoma when these screening and treatment programs are utilized by women.
A 40-year-old divorced mother of four school-age children is hospitalized with metastatic cancer of the ovary. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. The most appropriate response by the nurse is A. "Why don't we talk about the options you have for the care of your children?" B. "Many patients with cancer live for a long time, so there is time to plan for your children." C. "For now you need to concentrate on getting well, not worry about your children." D. "Perhaps your ex-husband will take the children when you can't care for them."
Answer: A. "Why don't we talk about the options you have for the care of your children?" Rationale: This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans.
A 58-year-old woman calls the health clinic when she has a moderate amount of vaginal bleeding after 6 years of menopause. The nurse will anticipate scheduling the patient for A. endometrial biopsy. B. dilation and curettage (D&C). C. laser endometrial ablation. D. uterine balloon therapy.
Answer: A. endometrial biopsy Rationale: A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer, and endometrial biopsy is the primary test for endometrial cancer. D&C will be needed only if the biopsy does not provide sufficient information to make a diagnosis. Endometrial ablation and balloon therapy are used to treat menorrhagia, which is unlikely in this patient
Nausea and vomiting are common adverse effects of radiation. When should a nurse administer antiemetics? A: 30 minutes before the initiation of therapy B: With the administration of therapy C: Immediately after nausea begins D: When therapy is completed
Answer: A: 30 minutes before the initiation of therapy Rationale: Antiemetics are most beneficial when given before the onset of nausea and vomiting. If the antiemetic was given with the medication or after the medication, it could lose its maximum effectiveness when needed.
The nurse is caring for a 35-year old patient receiving radiation and chemotherapy. Which statement by the patient indicates that he is using a positive coping mechanism that is useful during treatments? A: I may miss my own hair, but I have chosen a nice wig to wear B: Losing my hair won't bother me at all C: I'm never going to leave the house if I am bald D: I will not lose my hair and I'll make sure of that
Answer: A: I may miss my own hair, but I have chosen a nice wig to wear Rationale: Expressing personal feelings and positive interventions demonstrate positive coping mechanisms
After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan? A: Nutritional intake B: Management of alopecia C: Exercise and activity levels D: Access to community resources
Answer: A: Nutritional intake Rationale: Clients who have had gastric surgery are prone to postoperative complications, such as dumping syndrome and postprandial hypoglycemia, which can affect nutritional intake. Vitamin absorption can also be an issue, depending on the extent of the gastric surgery. Radiation therapy to the upper gastrointestinal area also can affect nutritional intake by causing anorexia, nausea, and esophagitis. The client would not be expected to develop alopecia. Exercise and activity levels as well as access to community resources are important teaching areas, but nutritional intake is a priority need.
A client undergoing radiation therapy has a severely depressed WBC count. The nurse should include which priority nursing intervention in the plan of care? A: Place the client in a private room and maintain strict aseptic technique with all procedures B: Encourage the client to include fresh fruits and vegetables in the diet C: Educate the client to avoid shaving with a razor D: Encourage frequent visitors to reduce the client's feelings of isolation
Answer: A: Place the client in a private room and maintain strict aseptic technique with all procedures Rationale: The immunosuppressed client is at a high risk for infection. A private room, maintaining aseptic technique, and limiting visitors will reduce exposure and risk.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A. Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Avoiding arm exercises in the immediate post-operative period. D. Maintaining an intravenous site below the antecubital area of the affected side
Answer: B Rationale: Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring
While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumors A. Do not cause damage to adjacent tissue. B. Do not spread to other tissues and organs. C. Are simply an overgrowth of normal cells. D. Frequently recur in the same site.
Answer: B Rationale: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.
A patient has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast if which behavior is observed? A. Performs arm exercises B. Refuses to look at the dressing C. Reads the post operative care booklet D. Requests pain medication when needed
Answer: B Rationale: The patient demonstrated the most difficult adjustments to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Performing arm exercises is an action oriented behavior on the part of the patient and is considered a positive sign of adjustment. Reading the post operative care booklet indicates an interest in self care and is a positive action oriented option that is helpful, although there is no direct connection to adjustment to the loss of the breast.
7) The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which of the following abnormalities associated with this oncologic emergency? A. Hypokalemia B. Hypocalcemia C. Hypouricemia D. Hypophosphatemia
Answer: B - Hypocalcemia
A 50 year old female client complains of bloating and indigestion and tells the nurse she has gained two inches in her waist recently. Which question should the nurse ask the client? A:"What do you eat before you feel bloated?" B:"Have you had your ovaries removed?" C:"Are your stools darker in color lately?" D:"Is this indigestion worse when you lie down?"
Answer: B. "Have you had your ovaries removed?" Rationale: Ovarian Cancer has vague symptoms of abdominal discomfort, but increasing abdominal girth is the most common symptom. If the client has had the ovaries removed, then the nurse could assess for another cause.
A female client has a mother who died from ovarian cancer and sister diagnosed with it. Which recommendations should the nurse make regarding early detection of ovarian cancer? A:The client should consider having a prophylactic bilateral oophorectomy B:The client should have a trans-vaginal ultrasound and a CA-125 lab test every 6 months C:The client should have yearly MRI scans D:The client should have a biannual gyn exam with flexible sigmoidoscopy
Answer: B. The client should have a trans-vaginal ultrasound and a CA-125 lab test every 6 months Rationale: A trans-vaginal ultrasound is a sonogram probe is inserted into the vagina and sound waves are directed toward the ovaries. The CA-125 tumor marker is elevated in several cancers. It is nonspecific but, coupled with the sonogram, can provide info about ovarian cancer for early diagnosis.
The nurse is visiting a patient receiving radiation therapy. Which of the following statements is incorrect and requires additional teaching? A: "I may lose the ability to sweat" B: "To keep the radiation from burning my skin, I will use lotion" C: "I need to check my mouth frequently for signs of irritation" D: "During radiation therapy, I may lose some of my hair and foods may not taste right"
Answer: B: "To keep the radiation from burning my skin, I will use lotion" Rationale: Skin products must be prescribed by the physician because they can irritate the skin
When teaching safety precautions to the client with internal radiation implant, the nurse would include which statement in explanations to the client? A: No precautions are necessary for internal radiation therapy implants B: The client poses a risk of radiation exposure to others C: The client must remain in solitary isolation for the entire hospitalization D: Visitors should maintain a distance of 30 feet from the client at all times
Answer: B: The client poses a risk of radiation exposure to others Rationale: Internal radiation is emitted outward to people in close contact as long as the implant is in place. Therefore, certain precautions to protect others must be taken: The client should have a private room, and visitors should maintain a distance of 6 feet and limit visits to 10-30 minutes.
A hospitalized client with an internal radiation implant calls the nurse to the room to report the implant is dislodged and is lying in the bed. The nurse's actions would include which of the following? A: Apply gloves and place implant in a biohazard bag B: Use long-handled forceps to pick up the implant and place it into lead container C: Have client pick up the implant and place it into lead container D: Notify infection control personnel to dispose of implant
Answer: B: Use long-handled forceps to pick up the implant and place it into lead container Rationale: Direct handling of the implant causes exposure to radiation and no one should directly touch the implant. Gloves and biohazard bags do not offer protection from radiation. Long-handled forceps should be used to pick up the implant and lead containers are necessary to prevent exposure to radiation.
When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: a.Discourage the use of stool softeners b.Assess temperature readings every six hours c.Avoid invasive procedures d.Encourage the use of a hard, bristle toothbrush
Answer: C Rationale: Thrombocytopenia is a deficiency of platelets, and leaves the patient more prone to hemorrhage. For this reason, avoiding invasive procedures will limit the risk of hemorrhage. Stool softeners should be encouraged, while hard bristle toothbrushes should be avoided. Temperature is not the most important vital to track in this patient
A 58 year old female is concerned about her risk for developing breast cancer. She began menarche at age 14, had 3 children before the age of 35, went through menopause at age 50 with an associated weight gain of 20 lbs. Which of the risk factors would contribute to this client's risk of developing breast cancer? A. menarche at age 14 B. children before the age of 35 C. postmenopausal obesity D. menopause at age 50
Answer: C Rationale: Postmenopausal obesity is a risk factor for developing breast cancer
10. What would be most important for the nurse to teach the patient to protect themselves from infection? A) Avoiding crowds and taking antipyretics such as Aspirin TID to avoid a fever. B) Assessing their vital signs weekly and reporting a persistent fever of 102 degrees or greater. C) Bathing daily and washing their hands frequently, especially after using restroom or handling contaminated objects. D) Interacting only with individuals who have recently been vaccinated with live or attenuated vaccines.
Answer: C - Bathing daily and washing their hands frequently, especially after using restroom or handling contaminated objects.
When planning care for a client being treated for cervical cancer, it would be a priority for the nurse to include which of the following in the plan of care? A. Instruction on birth control methods. B. Vigorous fluid hydration. C. Assessment of sexual function. D. Daily weights.
Answer: C. Assessment of sexual function. Rationale: Surgery and radiation therapy for cervical cancer often result in shortening of the vagina, vaginal dryness, and loss of libido due to emotional issues related to sexuality and femininity. Therefore, the client's feelings about sexuality and the partner's feelings should be assessed. If a client is not sexually active, instructions should be given in the use of a vaginal dilator and lubricant to prevent adhesion of the vaginal walls. While instruction about birth control methods may be needed for some clients, treatment for cervical cancer may include total abdominal hysterectomy, so that this would not be appropriate for all clients. Encouraging fluids and daily weights are not priorities for cervical cancer care.
The nurse is making a home visit to a client receiving external radiation therapy on an outpatient basis. Further teaching is necessary when the nurse observes the client doing which of the following? A: Washing radiation site with plain water and patting skin dry B: Protecting skin with soft, loose clothing C: Applying lotion to irritated skin D: Inspecting skin for damage
Answer: C: Applying lotion to irritated skin Rationale: Lotion, deodorant, and powders should not be applied to the radiation site during the treatment period to avoid further irritation to the skin.
The nurse is caring for a client admitted to the surgical unit following a right modified radical mastectomy. The nurse includes which of the following in the nursing plan of care? A. Take blood pressure in the right arm only. B. Draw serum laboratory samples from the right arm only. C. Position the client supine with the right arm elevated on a pillow. D. Check the right posterior axilla area when assessing the surgical dressing.
Answer: D Rationale: If there is drainage or bleeding from the surgical site after a mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the drainage first. The nurse checks this area to detect early bleeding. The patient should be positioned with the head of the bed in semi-Fowler's position and the arm elevated on pillows to decrease edema. Edema is likely to occur because lymph drainage channels have been resected during the surgical procedure. Blood pressure management, venipuncture, and intra-venous sites should not involve use of the operative arm.
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patient's nutritional intake? A) Increase intake of liquids at mealtime to stimulate appetite. B) Serve three large meals per day plus snacks between each meal C) Avoid the use of liquid protein supplements to encourage eating at mealtime D) Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
Answer: D - Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
5) A nurse is caring for a client who was admitted to receive chemotherapy for treatment of ovarian cancer. The client vomited after each previous dose of chemotherapy. Which of the following actions should the nurse take to prevent vomiting? A. Speak to the provider about decreasing the chemotherapy dose B. Withhold food and fluids prior to and during treatment C. Provide the client with an emesis basin during treatment D. Administer and antiemetic prior to chemotherapy
Answer: D - Administer an antiemetic prior to chemotherapy
Mina, who is suspected of an ovarian tumor, is scheduled for a pelvic ultrasound. The nurse provides which pre-procedure instruction to the client? A. Eat a light breakfast only B. Maintain an NPO status before the procedure C. Wear comfortable clothing and shoes for the procedure D. Drink six to eight glasses of water without voiding before the test
Answer: D. Drink six to eight glasses of water without voiding before the test Rationale: A pelvic ultrasound requires the ingestion of large volumes of water just before the procedure. A full bladder is necessary so that it will be visualized as such and not mistaken for a possible pelvic growth. An abdominal ultrasound may require that the client abstain from food or fluid for several hours before the procedure. Option C is unrelated to this specific procedure.
A woman tells the nurse that "there's been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer? A. Pain B. Leg edema C. Urinary and rectal symptoms D. Light bleeding or watery vaginal discharge
Answer: D. Light bleeding or watery vaginal discharge. Rationale: In its early stages, cancer of the cervix is usually asymptomatic, which underscores the importance of regular Pap smears. A light bleeding or serosanguineous discharge may be apparent as the first noticeable symptom. Pain, leg edema, urinary and rectal symptoms, and weight loss are late signs of cervical cancer.
A 22 year old client asks about the purpose of the HPV vaccine (Gardasil). What is an appropriate nursing explanation? A. It is to lower the risk of contracting melanoma. B. It is a vaccine that prevents infection by all strains of HPV. C. The vaccine treats infections of HPV. D. The vaccine can lower the risk of cervical cancer.
Answer: D. The vaccine can lower the risk of cervical cancer. Rationale: The HPV vaccine can prevent infection by certain strains of HPV, not all strains. It is useful in that it can lower the risk of developing cervical cancer. It does not treat preexisting infection, but can prevent infection by other types.
A nurse is counseling the family of patient who has terminal breast cancer about palliative care. The nurse explains that which of the following are goals of palliative care? Select all that apply. A. Delays death B. Offers a support system C. Provides relief from pain D. Enhances the quality of life E. Focuses only on the patient not the family F. Manages symptoms of disease and therapies
Answers: B, C, D, F Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: providing relief from pain and other distressing symptoms, affirming life and regarding dying as a normal process, neither hastening nor postponing death, integrating psychological and spiritual aspects of client care, offering a support system to help the client live as actively as possible until death, offering a support system to help families cope during the client's illness and their own bereavement, and enhancing the quality of life.
When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."
B Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.
20. A patient who is receiving interleukin-2 (IL-2) therapy (Proleukin) complains to the nurse about all of these symptoms. Which one is most important to report to the health care provider? a. Generalized aches b. Dyspnea c. Decreased appetite d. Insomnia
B Rationale: Dyspnea may indicate capillary leak syndrome and pulmonary edema, which requires rapid treatment. The other symptoms are common with IL-2 therapy, and the nurse should teach the patient that these are common adverse effects that will resolve at the end of the therapy.
10. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. increase energy and sense of well-being, which will help with body image. b. facilitate weight loss, which will decrease peripheral insulin resistance. c. improve cardiovascular endurance, which is important for diabetics. d. set a successful pattern, which will help in making other needed changes.
B Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. Increased energy, improved cardiovascular endurance, and setting a pattern of success are secondary benefits of exercise, but they are not the major reason. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity
25. The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient may indicate a need for a change in treatment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I take acetaminophen (Tylenol) every 4 hours." d. "I experience chills after I inject the interferon."
B Rationale: Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use Tylenol every 4 hours.
24. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. The nurse teaches the patient that the purpose of therapy with this agent is to a. protect normal kidney cells from the damaging effects of chemotherapy. b. enhance the patient's immunologic response to tumor cells. c. stimulate malignant cells in the resting phase to enter mitosis. d. prevent the bone marrow depression caused by chemotherapy.
B Rationale: IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.
12. A patient with type 1 diabetes has an unusually high morning glucose measurement, and the health care provider wants the patient evaluated for possible Somogyi effect. The nurse will plan to a. administer an increased dose of NPH insulin in the evening. b. obtain the patient's blood glucose at 3:00 in the morning. c. withhold the nighttime snack and check the glucose at 6:00 AM. d. check the patient for symptoms of hypoglycemia at 2:00 to 4:00 AM.
B Rationale: In the Somogyi effect, the patient's blood glucose drops in the early morning hours (in response to excess insulin administration), which causes the release of hormones that result in a rebound hyperglycemia. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia. An increased evening NPH dose or holding the nighttime snack will further increase the risk for early morning hypoglycemia. Information about symptoms of hypoglycemia will not be as accurate as checking the patient's blood glucose in determining whether the patient has the Somogyi effect. Cognitive Level: Application Text Reference: pp. 1263-1264 Nursing Process: Planning NCLEX: Physiological Integrity
1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes a. the patient is totally dependent on an outside source of insulin. b. there is decreased insulin secretion and cellular resistance to insulin that is produced. c. the immune system destroys the pancreatic insulin-producing cells. d. the insulin precursor that is secreted by the pancreas is not activated by the liver.
B Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity
25. A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl, the nurse advises the patient to a. use only the lispro insulin until the symptoms of infection are resolved. b. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. c. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. d. limit intake to non-calorie-containing liquids until the glucose is within the usual range.
B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose. Cognitive Level: Application Text Reference: p. 1272 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
26. Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider? a. Hemoglobin of 10 g/L b. WBC count of 1700/µl c. Platelets of 65,000/µl d. Serum creatinine level of 1.2 mg/dl .
B Rationale: Neutropenia places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim (Neupogen) are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy
4. In teaching about cancer prevention to a community group, the nurse stresses promotion of exercise, normal body weight, and low-fat diet because a. most people are willing to make these changes to avoid cancer. b. dietary fat and obesity promote growth of many types of cancer. c. people who exercise and eat healthy will make other lifestyle changes. d. obesity and lack of exercise cause cancer in susceptible people.
B Rationale: Obesity and dietary fat promote the growth of malignant cells, and decreasing these risk factors can reduce the chance of cancer development. Many people are not willing to make these changes. Good diet and exercise habits are not a guarantee that other healthy lifestyle changes will then occur. Obesity and lack of exercise do not cause cancer, but they promote the growth of altered cells.
3. During a diabetes screening program, a patient tells the nurse, "My mother died of complications of type 2 diabetes. Can I inherit diabetes?" The nurse explains that a. as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented. b. the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing. c. there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes. d. although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes.
B Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercising. The risk for children of a person with type 1 diabetes to develop diabetes is higher when it is the father who has the disease. Offspring of people with type 2 diabetes are more likely to develop diabetes than offspring of those with type 1 diabetes. Cognitive Level: Application Text Reference: p. 1256 Nursing Process: Implementation NCLEX: Physiological Integrity
34. The health care provider orders oral glucose tolerance testing for a patient seen in the clinic. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient had a viral illness 2 months ago. b. The patient uses oral contraceptives. c. The patient runs several days a week. d. The patient has a family history of diabetes.
B Rationale: Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. A viral 2 months previously illness may be associated with the onset of type 1 diabetes but will not falsely impact the OGTT. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. Cognitive Level: Application Text Reference: p. 1267 Nursing Process: Assessment NCLEX: Physiological Integrity
14. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse knows that teaching about management of the skin reaction has been effective when the patient says a. "I can use ice packs to relieve itching in the treatment area." b. "I can buy a steroid cream to use on the itching area." c. "I will expose the treatment area to a sun lamp daily." d. "I will scrub the area with warm water to remove the scales."
B Rationale: Steroid (over-the-counter [OTC] hydrocortisone) cream may be used to reduce itching in the area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.
13. A patient receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between a. 8:00 and 10:00 AM. b. 4:00 and 6:00 PM. c. 7:00 and 9:00 PM. d. 10:00 PM and 12:00 AM.
B Rationale: The greatest insulin effect with this combination occurs mid afternoon. The patient is not at a high risk at the other listed times, although hypoglycemia may occur. Cognitive Level: Comprehension Text Reference: p. 1260 Nursing Process: Evaluation NCLEX: Physiological Integrity
21. A 32-year-old male patient is to undergo radiation therapy to the pelvic area for Hodgkin's lymphoma. He expresses concern to the nurse about the effect of chemotherapy on his sexual function. The best response by the nurse to the patient's concerns is a. "Radiation does not cause the problems with sexual functioning that occur with chemotherapy or surgical procedures used to treat cancer." b. "It is possible you may have some changes in your sexual function, and you may want to consider pretreatment harvesting of sperm if you want children." c. "The radiation will make you sterile, but your ability to have sexual intercourse will not be changed by the treatment." d. "You may have some temporary impotence during the course of the radiation, but normal sexual function will return."
B Rationale: The impact on sperm count and erectile function depends on the patient's pretreatment status and on the amount of exposure to radiation. The patient should consider sperm donation before radiation. Radiation (like chemotherapy or surgery) may affect both sexual function and fertility either temporarily or permanently.
1. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumors a. do not cause damage to adjacent tissue. b. do not spread to other tissues and organs. c. are simply an overgrowth of normal cells. d. frequently recur in the same site.
B Rationale: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.
35. Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%
B Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient. Cognitive Level: Application Text Reference: pp. 1281-1282 Nursing Process: Assessment NCLEX: Physiological Integrity
17. A chemotherapeutic agent known to cause alopecia is prescribed for a patient. To maintain the patient's self-esteem, the nurse plans to a. suggest that the patient limit social contacts until regrowth of the hair occurs. b. encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. have the patient wash the hair gently with a mild shampoo to minimize hair loss. d. inform the patient that hair loss will not be permanent and that the hair will grow back.
B Rationale: The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.
30. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient that a. the feet should be soaked in warm water on a daily basis. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. heating pads should always be set at a very low temperature. d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.
B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems. Cognitive Level: Application Text Reference: p. 1287 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
8. The nurse is teaching a postmenopausal patient with breast cancer about the expected outcomes of her cancer treatment. The nurse evaluates that the teaching has been effective when the patient says a. "After cancer has not recurred for 5 years, it is considered cured." b. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured." c. "Cancer is considered cured if the entire tumor is surgically removed." d. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." .
B Rationale: The risk of recurrence varies by the type of cancer; for breast cancer in postmenopausal women, the patient needs at least 20 disease-free years to be considered cured. Some cancers (e.g., leukemia) are cured by nonsurgical therapies such as radiation and chemotherapy
A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? a. avoid sick people and wash hands. b. obtain comprehensive dental care. c. maintain hemoglobin A1c below 7%. d. coughing and deep breathing with splinting
B - A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1c below 7%, and coughing and deep breathing with splinting would be important for any type of surgery, but not the priority with mitral valve replacement for this patient.
Which patient is most likely to experience anemia related to an increased destruction of red blood cells? a. A 59-year-old man whose alcoholism has precipitated folic acid deficiency b. A 23-year-old African American man who has a diagnosis of sickle cell disease c. A 30-year-old woman with a history of "heavy periods" accompanied by anemia d. A 3-year-old child whose impaired growth and development is attributable to thalassemi
B - A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.
During the admission assessment, the nurse discovers that the patient has used illicit drugs. Related to the hematologic system, what question should the nurse next ask the patient? a. "Do you have any blood in your stools?" b. "What agent and when did you last use it?" c. "Have you had any surgeries causing pain?" d. "Do you have shortness of breath with activity?"
B - Although all these questions are appropriate related to the hematologic system, the only one related specifically to illicit drug use is asking about what agent and when it was last used. The route and frequency should also be assessed.
Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? a. 5 b. 15 c. 30 d. 60
B - As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.
A 57-year-old patient has been diagnosed with acute myelogenous leukemia (AML). The nurse explains to the patient that collaborative care will focus on what? a. leukapheresis b. attaining remission c. one chemotherapy agent d. waiting with active supportive care
B - Attaining remission is the initial goal of collaborative care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the WBC count and risk of leukemia-cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia (CLL), waiting may be done to attain remission, but not with AML.
The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? a. immediately pick up both units of blood from the blood bank. b. infuse the blood slowly for the first 15 minutes of the transfusion. c. regulate the flow rate so that each unit takes at least 4 hours to transfuse. d. set up the Y-tubing of the blood set with dextrose in water as the flush solution.
B - Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging a unit of blood. Only one unit of blood can be picked up at a time, must be infused within 4 hours, and cannot be hung with dextrose.
What nursing intervention should be the priority in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)? a. administration of packed red blood cells b. administration of oral or IV corticosteroids c. administration of clotting factors VIII and IX d. maintenance of reverse isolation and application of standard precautions
B - Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.
The nurse is reviewing the objective data from a patient with suspected allergies. Which assessment finding does the nurse know indicates allergies? Tab 1 - Physical Examination Dry cough Pale skin Tab 2 - Laboratory Results Neutrophils: 60% Eosinophils: 10% Basophils: 1% Lymphocytes: 20% Monocytes: 6% Tab 3 - Medications Acetaminophen 1000 mg every 12 hours Levothyroxine (Synthroid) 125 mcg each day a. dry cough b. eosinophil result c. lymphocyte result d. acetaminophen use
B - Eosinophils are granulocytes that phagocytize antigen-antibody complexes formed during an allergic response. The normal eosinophil count is 2% to 4% of all WBCs. The dry cough, lymphocyte result, and acetaminophen use do not indicate allergies.
When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about: a. folic acid intake b. dietary intake of iron c. a history of gastric surgery d. a history of sickle cell anemia
B - Iron-deficiency anemia is a microcytic, hypochromic anemia.
The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. What information is appropriate for the nurse to include? a. macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. b. microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. c. renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. d. macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.
B - Microangiopathy occurs in diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.
An individual who lives at high altitudes may normally have an increased RBC count because: a. high altitudes cause vascular fluid loss, leading to hemoconcentration b. hypoxia caused by decreased atmospheric oxygen stimulates erythropoiesis c. the function of the spleen in removing old RBCs is impaired at high altitudes d. impaired production of leukocytes and platelets leads to proportionally higher red cell counts
B - Normal physiologic increases in the red blood cell count occur at high altitudes. At high altitudes, less atmospheric weight pushes air into the lungs; the partial pressure of oxygen is thereby decreased, which causes hypoxia. Erythropoiesis is stimulated by hypoxia and controlled by erythropoietin, a glycoprotein growth factor synthesized and released by the kidneys. Erythropoietin stimulates the bone marrow to increase erythrocyte production.
The nurse is providing care for older adults on a subacute, geriatric medicine unit. What effect is aging likely to have on hematologic function of older adults? a. thrombocytosis b. decreased hemoglobin c. decreased WBC count d. decreased blood volume
B - Older adults frequently experience decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.
When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What should the nurse place highest priority on initiating interventions to reduce? a. thirst b. fatigue c. headache d. abdominal pain
B - The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.
A 22-year-old female patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? a. brentuximab vedotin (Adcetris) b. two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine c. four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine d. BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone
B - The patient with stage favorable prognosis early-stage Hodgkin's lymphoma will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.
A 51-year-old patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time? a. 6:00 PM on the evening before the test b. midnight before the test c. 4:00 AM on the day of the test d. 7:00 AM on the day of the test
B - Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.
An anticoagulant such as warfarin (Coumadin) that interferes with prothrombin production will alter the clotting mechanisms during: a. platelet aggregation b. activation of thrombin c. the release of tissue thromboplastin d. stimulation of factor activation complex
B - Warfarin inhibits the effective synthesis of vitamin K-dependent clotting factors: II (prothrombin), VII (stable factor), IX (Christmas factor), and X (Stuart-Prower factor) in the extrinsic pathway. Thrombin is not activated, and coagulation is interrupted in the final common pathway of the clotting cascade. Without thrombin activation, fibrinogen is not converted to fibrin, and blood clotting does not occur.
A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean that the client has: A Active TB B Had contact with Mycobacterium tuberculosis C Developed a resistance to tubercle bacilli D Developed passive immunity to TB
B) A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists.
When preparing the newly diagnosed client with HIV and significant other for discharge, which explanation by the nurse accurately describes proper condom use? A) ''Condoms should be used when lesions on the penis are present.'' B) ''Always position the condom with a space at the tip of an erect penis.'' C) ''Make sure it fits loosely to allow for penile erection.'' D) ''Use adequate lubrication such as petroleum jelly.''
B) B) ''Always position the condom with a space at the tip of an erect penis.'' Rationale: This allows for the collection of semen at the tip of the condom.
INH treatment is associated with the development of peripheral neuropathies. Which of the following interventions would the nurse teach the client to help prevent this complication? A Adhere to a low cholesterol diet B Supplement the diet with pyridoxine (vitamin B6) C Get extra rest D Avoid excessive sun exposure
B) INH competes with the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed.
A client has active TB. Which of the following symptoms will he exhibit? A) Chest and lower back pain B) Chills, fever, night sweats, and hemoptysis C) Fever of more than 104*F and nausea D) Headache and photophobia
B) Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn't usual. Clients with TB typically have low-grade fevers, not higher than 102*F. Nausea, headache, and photophobia aren't usual TB symptoms.
What is the first intervention for a client experiencing MI? A) Administer morphine B) Administer oxygen C) Administer sublingual nitroglycerin D) Obtain an ECG
B) Administer oxygen Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI
The nurse prepares discharge teaching for a client receiving isosorbide dinitrate for treatment of angina. What information must the nurse include? A) Limit exercise to 30 minutes twice per week. B) Avoid alcohol consumption. C) Monitor intake and output. D) Report skin flushing to the physician.
B) Avoid alcohol consumption.
Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A) Antihypertensives B) Beta-adrenergic blockers C) Calcium channel blockers D) Nitrates
B) Beta-adrenergic blockers By decreasing the heart rate and contractility, beta-blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Antihypertensives aren't usually indicated because they would decrease cardiac output in clients who are already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-blockers; however, they aren't as effective as beta-blockers and cause increased hypotension. Nitrates aren't used because of their dilating effects, which would further compromise the myocardium.
The nurse recognizes that calcium channel blockers prescribed for treatment of angina exert their effect by: A) Increasing preload. B) Decreasing afterload. C) Positive chronotropic effect. D) Positive inotropic effect.
B) Decreasing afterload. Rationale: Calcium channel blockers cause arteriolar smooth muscle relaxation, leading to lowered peripheral resistance and decreased blood pressure (decreased afterload). This decreases myocardial oxygen demand, and reduces frequency of anginal pain.
What does the nurse include in the teaching plan for a client receiving a beta blocker for treatment of angina? A) Discontinue drug if heart rate <60. B) Do not discontinue drug abruptly. C) Exercise heart rate should be 110-120. D) Monitor for hyperglycemia.
B) Do not discontinue drug abruptly. Rationale: Beta blocker treatment should never be abruptly discontinued. With abrupt cessation, a rebound excitation occurs, and adrenergic receptors are stimulated. This can exacerbate angina, increase heart rate, and cause myocardial infarction. Clients often tolerate heart rates as low as 50. The beta blocker might blunt the compensatory increase in heart rate with exercise. Hypoglycemia can occur.
A 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During the admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago because he was feeling better. Which of the following nursing diagnoses takes priority for this client? A) Anxiety B) Ineffective tissue perfusion; cardiopulmonary C) Acute pain D) Ineffective therapeutic regimen management
B) Ineffective tissue perfusion; cardiopulmonary MI results from prolonged myocardial ischemia caused by reduced blood flow through the coronary arteries. Therefore, the priority nursing diagnosis for this client is Ineffective tissue perfusion (cardiopulmonary). Anxiety, acute pain, and ineffective therapeutic regimen management are appropriate but don't take priority
The nurse recognizes that the mechanism for action of beta-adrenergic blockers in the treatment of angina is: A) Positive chronotropic effect. B) Negative inotropic effect. C) Positive inotropic effect. D) Antidysrhythmia.
B) Negative inotropic effect. Rationale: Beta blockers decrease the workload of the heart by slowing heart rate (negative chronotropic effect) and reducing contractility (negative inotropic effect).
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of MI? A) Liquids as ordered B) Small, easily digested meals C) Three regular meals per day D) NPO
B) Small, easily digested meals Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.
Which of the following control systems play a major role in maintaining blood pressure? Select All That Apply A. Renovascular system B. Arterial baroreceptor system C. Regulation of body fluid volume D. Respiratory System E. Renin-angiotensin-aldosterone system F. Vascular autoregulation G. Pulmonary system
B, C, E, F
When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) A. Explain to the client that the colostomy is only temporary. B. Encourage the client to participate in changing the ostomy. C. Obtain a psychiatric consultation. D. Offer to have a person who is coping with a colostomy visit. E. Encourage the client and family members to express their feelings and concerns.
B, D, E Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.
The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply. A "I will need to dispose of my old clothing when I return home." B "I should always cover my mouth and nose when sneezing." C "It is important that I isolate myself from family when possible." D "I should use paper tissues to cough in and dispose of them properly." E "I can use regular plate and utensils whenever I eat."
B, D, and E
The nurse reviews the chart of a client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? A. "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." B. "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." C. "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." D. "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation."
B. "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means that no distant metastasis has occurred. NX means that no regional lymph nodes can be assessed. A glioma is a benign tumor of the brain, but the client is diagnosed with a glioblastoma, which means a malignant tumor of the glial cells of the brain.
Because myelodysplastic syndrome arises from hematopoietic stem cell in the bone marrow, laboratory results the nurse would expect to find include: A. A deficiency of granulocytes B. A deficiency of all cellular blood components C. An excess of T cells D. An excess of platelets
B. A deficiency of all cellular blood components
When caring for the client with hyperuricemia associated with tumor lysis syndrome (TLS), for which medication does the nurse anticipate an order? A. Recombinant erythropoietin (Procrit) B. Allopurinol (Zyloprim) C. Potassium chloride D. Radioactive iodine-131 (131I)
B. Allopurinol (Zyloprim) TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; allopurinol decreases uric acid production and is indicated in TLS. Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.
The patient is admitted to the ED with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing measures will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply)? A. Assessment of lung sounds B. Assessment of sexual behavior C. Assessment of living conditions D. Assessment of drug and syringe use E. Assessment of exposure to an ill person
B. Assessment of sexual behavior D. Assessment of drug and syringe use With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for the HIV virus should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).
The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? A. Vomiting B. Back pain C. Frequent urination D. Cyanosis of the toes
B. Back pain Typical sites of breast cancer metastasis include bone (manifested by back pain), lung, liver, and brain. Signs of metastasis to the spine may include numbness, pain, paresthesias and tingling, and loss of bowel and bladder control, but not vomiting. Although frequent urination may be a sign of bladder cancer, incontinence is more indicative of spinal metastasis. Cyanosis of the toes indicates decreased tissue perfusion, often related to atherosclerotic disease.
The nurse is caring for a patient newly diagnosed with HIV. The patient asks what would determine the actual development of AIDS. The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS? A. Presence of HIV antibodie B. CD4+ T cell count below 200/µL C. Presence of oral hairy leukoplakia D. White blood cell count below 5000/µl
B. CD4+ T cell count below 200/µL Diagnostic criteria for AIDS include a CD4+ T cell count below 200/µL and/or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The other options may be found in patients with HIV disease but do not define the advancement of HIV infection to AIDS.
Rh-negative mother should receive Rho (D) Immune Globulin after which test are performed? A. AFP B. Chorionic villus sampling C. Amniocentesis D. Ultrasound E. Contraction Stress tes
B. Chorionic villus sampling C. Amniocentesis
The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manager
B. Combination antiretroviral therapy Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first.
The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? A. Easy bruising B. Dyspnea C. Night sweats D. Chest wound
B. Dyspnea Dyspnea is a sign of lung cancer, as are cough, hoarseness, shortness of breath, bloody sputum, arm or chest pain, and dysphagia. Easy bruising is a nonspecific finding. Night sweats is a symptom of the lymphomas. A chest wound is not specific to lung cancer.
Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A. New onset of fatigue B. Edema of arms and hands C. Dry cough D. Weight gain
B. Edema of arms and hands Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.
With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body
B. Lowering the limb so it is dependent
The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A. Cure of the cancer B. Relief of symptoms or improved quality of life C. Allowing other therapies to be more effective D. Prolonging the client's survival time
B. Relief of symptoms or improved quality of life The focus of palliative surgery is to improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.
Which activity performed by the community health nurse best reflects primary prevention of cancer? A. Assisting women to obtain free mammograms B. Teaching a class on cancer prevention C. Encouraging long-term smokers to get a chest x-ray D. Encouraging sexually active women to get annual Papanicolaou (Pap) smears
B. Teaching a class on cancer prevention Primary prevention involves avoiding exposure to known causes of cancer; education assists clients with this strategy. Mammography is part of a secondary level of prevention, defined as screening for early detection. Chest x-ray is a method of detecting a cancer that is present—secondary prevention and early detection. A Pap smear is a means of detecting cervical cancer early—secondary prevention.
38. A diabetic patient has a new order for inhaled insulin (Exubera). Which information about the patient indicates that the nurse should contact the patient before administering the Exubera? a. The patient has a history of a recent myocardial infarction. b. The patient's blood glucose is 224 mg/dl. c. The patient uses a bronchodilator to treat emphysema. d. The patient's temperature is 101.4° F.
C Rationale: Exubera is not recommended for patients with emphysema. The other data do not indicate any contraindication to using Exubera. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Assessment NCLEX: Physiological Integrity
24. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to a. administer glargine (Lantus) insulin. b. initiate oxygen by nasal cannula. c. insert a large-bore IV catheter. d. give 50% dextrose as a bolus.
C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Planning NCLEX: Physiological Integrity
29. A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, "I did not have any of the usual symptoms of hypoglycemia." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"
C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although -adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity
10. External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient that an important measure to prevent complications from the effects of the radiation is to a. test all stools for the presence of blood. b. inspect the mouth and throat daily for the appearance of thrush. c. perform perianal care with sitz baths and meticulous cleaning. d. maintain a high-residue, high-fat diet.
C Rationale: Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
7. A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient? a. The patient will have a diet and exercise plan that results in weight loss. b. The patient will state the reasons for eliminating simple sugars in the diet. c. The patient will have a glycosylated hemoglobin level of less than 7%. d. The patient will choose a diet that distributes calories throughout the day.
C Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority. Cognitive Level: Application Text Reference: p. 1273 Nursing Process: Planning NCLEX: Physiological Integrity
6. During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n) a. fasting blood glucose level. b. urine dipstick for glucose. c. glycosylated hemoglobin level. d. oral glucose tolerance test.
C Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed. Cognitive Level: Application Text Reference: pp. 1258-1259 Nursing Process: Planning NCLEX: Physiological Integrity
23. A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 U/hr. b. Give sodium bicarbonate 50 mEq IV push. c. Infuse 1 liter of normal saline per hour. d. Administer regular IV insulin 30 U.
C Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated. Cognitive Level: Application Text Reference: p. 1280 Nursing Process: Implementation NCLEX: Physiological Integrity
30. After the nurse has explained the purpose of and schedule for chemotherapy to a 23-year-old patient who recently received a diagnosis of acute leukemia, the patient asks the nurse to repeat the information. Based on this assessment, which nursing diagnosis is most likely for the patient? a. Acute confusion related to infiltration of leukemia cells into the central nervous system b. Knowledge deficit: chemotherapy related to a lack of interest in learning about treatment c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Risk for ineffective adherence to treatment related to denial of need for chemotherapy
C Rationale: The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors.
15. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to a. teach about the importance of nutrition during treatment. b. have the patient eat large meals when nausea is not present. c. administer prescribed antiemetics 1 hour before the treatments. d. offer dry crackers and carbonated fluids during chemotherapy.
C Rationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.
12. A patient with Hodgkin's lymphoma is undergoing external radiation therapy on an outpatient basis. After 2 weeks of treatment, the patient tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the nurse to plan with the patient is to a. exercise vigorously when fatigue is not as noticeable. b. consult with a psychiatrist for treatment of depression. c. establish a time to take a short walk every day. d. maintain bed rest until the treatment is completed.
C Rationale: Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Bed rest will lead to weakness and other complications of immobility.
28. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Fresh fruit salad b. Orange sherbet c. Strawberry yogurt d. French fries
C Rationale: Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. French fries are high in calories from fat but low in protein.
A patient, who is admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? a. central apnea b. hypoventilation c. kussmaul respirations d. Cheyne-Stokes respirations
C - In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.
DIC is a disorder in which: a. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature
C - In disseminated intravascular coagulation (DIC), the coagulation process is stimulated, with resultant thrombosis and depletion of clotting factors, which leads to diffuse clotting and hemorrhage. The paradox of this condition is characterized by the profuse bleeding that results from the depletion of platelets and clotting factors.
The nurse knows that hemolytic anemia can be caused by which extrinsic factors? a. trauma or splenic sequestration crisis b. abnormal hemoglobin or enzyme deficiency c. macroangiopathic or microangiopathic factors d. chronic diseases or medications and chemicals
C - Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of RBC precursors which reduce RBC production.
The newly diagnosed patient with type 2 diabetes has been prescribed metformin (Glucophage). What should the nurse tell the patient to best explain how this medication works? a. increases insulin production from the pancreas. b. slows the absorption of carbohydrate in the small intestine. c. reduces glucose production by the liver and enhances insulin sensitivity. d. increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying.
C - Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.
A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of: a. polyuria b. severe dehydration c. rapid, deep respirations d. decreased serum potassium
C - Signs and symptoms of DKA include manifestations of dehydration, such as poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early symptoms may include lethargy and weakness. As the patient becomes severely dehydrated, the skin becomes dry and loose, and the eyeballs become soft and sunken. Abdominal pain is another symptom of DKA that may be accompanied by anorexia and vomiting. Kussmaul respirations (i.e., rapid, deep breathing associated with dyspnea) are the body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is identified on the breath as a sweet, fruity odor. Laboratory findings include a blood glucose level greater than 250 mg/dL, arterial blood pH less than 7.30, serum bicarbonate level less than 15 mEq/L, and moderate to high ketone levels in the urine or blood.
When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? a. lactated Ringer's b. 5% dextrose in water c. 0.9% sodium chloride d. 0.45% sodium chloride
C - The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood as they will cause RBC hemolysis.
A 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? a. routine insulin therapy and exercise b. administer a different antibiotic for the UTI. c. cardiac monitoring to detect potassium changes d. administer IV fluids rapidly to correct dehydration.
C - This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.
After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care? a. administer heparin. b. administer whole blood. c. treat the causative problem. d. administer fresh frozen plasma.
C - Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.
A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take? a. eat a piece of pizza. b. drink some diet pop. c. eat 15 g of simple carbohydrates. d. take an extra dose of rapid-acting insulin.
C - When the patient with type 1 diabetes is unsure about the meaning of the symptoms she is experiencing, she should treat herself for hypoglycemia to prevent seizures and coma from occurring. She should also be advised to check her blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease her blood glucose.
An older patient relates that she has increased fatigue and a headache. The nurse identifies pale skin and glossitis on assessment. In response to these findings, which teaching will be helpful to the patient if she has microcytic, hypochromic anemia? a. take enteric-coated iron with each meal. b. take cobalamin with green leafy vegetables. c. take the iron with orange juice one hour before meals. d. decrease the intake of the antiseizure medications to improve.
C - With microcytic, hypochromic anemia, there may be an iron, B6, or copper deficiency, thalassemia, or lead poisoning. The iron prescribed should be taken with orange juice one hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help RBC maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. Changes in medications will be prescribed by the health care provider.
A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done? A To confirm the diagnosis B To determine if a repeat skin test is needed C To determine the extent of the lesions D To determine if this is a primary or secondary infection
C) If the lesions are large enough, the chest x-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest x-ray can't determine if this is a primary or secondary infection.
Which of the following conditions is most commonly responsible for myocardial infarction? A) Aneurysm B) Heart failure C) Coronary artery thrombosis D) Renal failure
C) Coronary artery thrombosis Coronary artery thrombosis causes an inclusion of the artery, leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn't cause an MI. Renal failure can be associated with MI but isn't a direct cause. Heart failure is usually a result from an MI.
The nurse determines that treatment of a client with a beta-adrenergic blocker for myocardial infarction has been effective when: A) Tachycardia occurs. B) Blood pressure is 90/50. C) Decreased dysrhythmias occur. D) Decreased urinary output occurs.
C) Decreased dysrhythmias occur. Rationale: Beta blockers have the ability to decrease heart rate, decrease contractility, and decrease blood pressure, leading to decreased oxygen demand. They also slow conduction, which suppresses dysrhythmias. Tachycardia would not be desired with an MI. A low BP alone would not indicate effective treatment of the MI.
If medical treatments fail, which of the following invasive procedures is necessary for treating cariomyopathy? A) Cardiac catherization B) Coronary artery bypass graft (CABG) C) Heart transplantation D) Intra-aortic balloon pump (IABP)
C) Heart transplantation The only definitive treatment for cardiomyopathy that can't be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.
Medical treatment of coronary artery disease includes which of the following procedures? A) Cardiac catherization B) Coronary artery bypass surgery C) Oral medication therapy D) Percutaneous transluminal coronary angioplasty
C) Oral medication therapy Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised. 3. Oral medication administration is a noninvasive, medical treatment for coronary artery disease. Cardiac catherization isn't a treatment, but a diagnostic tool. Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments.
Which of the following blood tests is most indicative of cardiac damage? A) Lactate dehydrogenase B) Complete blood count (CBC) C) Troponin I D) Creatine kinase (CK)
C) Troponin I Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren't detectable in people without cardiac injury. Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury.
What is the most common complication of an MI? A) Cardiogenic shock B) Heart failure C) arrhythmias D) Pericarditis
C) arrhythmias Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common complication of an MI. Cardiogenic shock, another complication of an MI, is defined as the end stage of left ventricular dysfunction. This condition occurs in approximately 15% of clients with MI. Because the pumping function of the heart is compromised by an MI, heart failure is the second most common complication. Pericarditis most commonly results from a bacterial or viral infection but may occur after the MI.
After attempting lifestyle changes with no improvement in the HTN, the nurse should expect the physician to prescribe which medication first? A. Calcium Channel Blocker B. ARB C. Thiazide diuretic D. Renin inhibitor
C. Thiazide diuretic is the first med to give, sometimes will be combined with a beta blocker. This combo is done so a lower dose of each med can be given.
A 52-year-old client relates to the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? A. "Don't worry, most lumps are discovered by women during breast self-examination." B. "Does anyone in your family have breast cancer?" C. "Finding a cancer in the early stages increases the chance for cure." D. "Have you noticed a lump or thickening in your breast?"
C. "Finding a cancer in the early stages increases the chance for cure." Providing truthful information addresses the client's concerns. Mammography can detect lumps smaller than those discovered by palpation. Asking about family history or symptoms is not therapeutic because it does not address the client's fear of cancer.
Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? A. "I may lose my hair during this treatment." B. "I must be positioned in the same way during each treatment." C. "I will have a radioactive device in my body for a short time." D. "I will be placed in a semiprivate room for company."
C. "I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.
A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the client is most important to communicate to the health care provider? A. "I am allergic to iodine." B. "My urinary stream is very weak." C. "My legs are numb and weak." D. "I am incontinent when I cough."
C. "My legs are numb and weak." Numbness and weakness should be reported to the physician because paralysis caused by spinal cord compression can occur. Prostate cancer may frequently metastasize to the bone, specifically the spine. Allergy to iodine should be reported when contrast media will be used, but dye is not used in radiation therapy. A weak urinary stream and incontinence are common clinical manifestations of prostate cancer. Incontinence associated with coughing is typical of stress incontinence and is not a complication of cancer.
An infant is born by vaginal delivery. At Birth the infant is crying. Respiration and pulse rate are good. One min after the birth the baby is noted with blue extremities. Five min later the extremities are pink. What are the 1 min and five min scores? A. 8/9 B. 8/10 C. 9/10 D. 9/7
C. 9/10 0-2 points given for cardiac tone, resp, muscle tone, color, reflexes
A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A. A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr
C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia. The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.
The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count
C. A sharp decrease in the patient's CD4+ count A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.
Rh-negative mother should receive Rho (D) Immune Globulin after which test are performed? A. AFP B. Chorionic villus sampling C. Amniocentesis D. Ultrasound E. Contraction Stress test B. Chorionic villus sampling
C. Amniocentesis
Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? A. Increasing shortness of breath B. Diminished bilateral breath sounds C. Change in mental status D. Weight gain of 4 pounds in 1 day
C. Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.
When providing care for a patient with thrombocytopenia, the nurse instructs the patient to: A. Continue with physical activities to stimulate thrombopoiesis B. Be careful when shaving with a safety razor C. Dab his or her nose instead of blowing D. Avoid aspirin because it may mask the fever that occurs with thrombocytopenia
C. Dab his or her nose instead of blowing
When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A. Administering a biological response modifier B. Encouraging oral care with commercial mouthwash C. Providing oral care with a disposable mouth swab D. Maintaining NPO until the lesions have resolved
C. Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.
The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A. The student scrubs the hub of IV tubing before administering an antibiotic. B. The nurse overhears the student explaining to the client the importance of handwashing. C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. D. The nurse observes the student providing oral hygiene and perineal care.
C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.
The woman is afraid she may get HIV from her bisexual husband. What should the nurse include when teaching her about preexposure prophylaxis (select all that apply)? A. Take fluconazole (Diflucan). B. Take amphotericin B (Fungizone). C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.
C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband. Using male or female condoms, having monthly HIV testing for the patient and her husband, and the woman taking emtricitabine and tenofovir regularly has shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcosus neoformans, which are all opportunistic diseases associate with HIV infection.
A client has undergone a lymph node biopsy. the nurse anticipates that the report will reveal which result if the client has Hodgkin's lymphoma? 1. Reed-Sternberg cells. 2. Philadelphia chromosome. 3. Epstein-Barr virus. 4. Herpes simplex virus.
CORRECT #1. RATIONALE: histological isolation of Reed-Sternberg cells in lymph node biopsy examination is a diagnostic feature of Hodgkin's lymphoma. Philadelphia chromosome is attributed to chronic myelogenous leukemia. viruses are much smaller than can be visualized with cytology.
The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy . The nurse notes that the platelet count is 20,000/ul. Based on the laboratory result, which intervention will the nurse document in the plan of care? 1. Monitor closely for signs of infection 2. Monitor the temperature every 4 hours 3. Initiate protective isolation precautions 4. Use soft small toothbrush for mouth care
Correct Ans 4 If a child is severely thrombocytopenic and has a platelet count less than 20,000/ul, bleeding precautions need to be initiated because of increased risk of bleeding or hemorrhage. Options 1,2,3 are related to the prevention of infection rather than bleeding
The female client recently diagnosed with Hodgkin's lymphoma asks the nurse about her prognosis. Which is the nurse's best response? 1.Survival for Hodgkin's disease is relatively good with standard therapy. 2.Survival depends on becoming involved in an investigational therapy program. 3.Survival is poor, with more than 50% of clients dying within six (6) months. 4.Survival is fine for primary Hodgkin's, but secondary cancers occur within a year.
Correct Answer: 1. 1.Up to 90% of clients responds well to standard treatment with chemotherapy and radiation therapy, and those that relapse usually respond to a change of chemotherapy medications. Survival depends on the individual client and the stage of disease at diagnosis. 2.Investigational therapy regimens would not be recommended for clients initially diagnosed with Hodgkin's because of the expected prognosis with standard therapy. 3.Clients usually achieve a significantly longer survival rate than six (6) months. Many clients survive to develop long-term secondary complications. 4.Secondary cancers can occur as long as 20 years after a remission of the Hodgkin's disease has occurred.
The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate
Correct Answer: A Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension b A 40-year-old female with obesity and metabolic syndrome c A 60-year-old male with renal insufficiency who is physically inactive d A 65-year-old female with hyperhomocysteinemia and substance abuse
Correct Answer: A The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.
A child with lymphoma is receiving extensive radiotherapy. Which of the following is the most common side effect of this treatment? A. malaise B. seizures C. neuropathy D. lymphadenopathy
Correct Answer: A 1. Malaise is the most common side effect of radiotherapy. For children, the fatigue may be especially distressing because it means they cannot keep up with their peers. 2. Seizures are unlikely because irradiation would not usually involve the cranial area for treatment of lymphoma. 3. Neuropathy is a side effect of certain chemotherapeutic agents. 4. Lymphadenopathy is one of the findings of lymphoma.
The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.
Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read.
Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer's disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective? a. The patient has less agitation. b. The patient is dressed appropriately. c. The patient is able to swallow a pill. d. The patient's speech is clearer.
Correct Answer: A Rationale: Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors.
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown
Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
A bone marrow transplant is being considered for treatment of a patient with acute leukemia that has not responded to chemotherapy. In discussing the treatment with the patient, the nurse explains that a. hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT). b. the transplant of the donated cells is painful because of the nerves in the tissue lining the bone. c. donor bone marrow cells are transplanted immediately after an infusion of chemotherapy. d. the transplant procedure takes place in a sterile operating room to minimize the risk for infection.
Correct Answer: A The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room required. The HSCT takes place 1 or 2 days after chemotherapy to prevent damage to the transplanted cells by the chemotherapy drug.
A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a Patient complains of chest pain with strenuous activity. b Patient says muscle leg pain occurs with continued exercise. c Patient has numbness and tingling of all his toes and both feet. d Patient states the feet become red if he puts them in a dependent position.
Correct Answer: B Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.
The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? a Assess output for renal dysfunction. b Use IV fluids to maintain adequate BP. c Use oral antihypertensives to maintain cardiac output. d Maintain a low BP to prevent pressure on surgical site
Correct Answer: B Rationale: The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.
A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient: A. To a private room so she will not infect other patients and healthcare workers B. To a private room so she will not be infected by other patients and healthcare workers C. To a semiprivate room so she will have stimulation during her hospitalization D. To a semiprivate room so she will have the opportunity to express her feelings about her illness
Correct Answer: B A. To a private room so she will not infect other patients and health care workers — poses little or no threat B. To a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection C. To a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone D. To a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness
A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.
Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has.
When teaching the spouse of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD can be made only when other causes of dementia have been ruled out. c. new drugs have been shown to reverse AD dramatically in some patients. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
Correct Answer: B Rationale: The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well.
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Move the patient to a quieter room at night. b. Open the blinds in the patient's room and provide frequent activities. c. Have the patient take a brief mid-morning nap. d. Provide hourly orientation to time of day.
Correct Answer: B Rationale: The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. have a close family member remain with the patient and provide reassurance. b. assign a staff member to stay with the patient and offer frequent reorientation. c. ask the health care provider about ordering an antipsychotic drug. d. secure the patient in bed with a soft chest restraint.
Correct Answer: B Rationale: The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
3. When administering a mental status examination to a patient with delirium, the nurse should a. give the examination when the patient is well-rested. b. reorient the patient as needed during the examination. c. choose a place without distracting environmental stimuli. d. medicate the patient first to reduce anxiety.
Correct Answer: C Rationale: Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.
A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house
Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications.
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to a. administer the PRN dose of lorazepam (Ativan). b. reorient the patient to time and place. c. assess the patient for anything that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.
Correct Answer: C Rationale: Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.
Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.
Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions.
When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d. Have the family bring in familiar items from the patient's home.
Correct Answer: C Rationale: Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. Use of "why" questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.
A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.
Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation.
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Where were you were born?" b. "Do have any feelings of sadness?" c. "What day of the week is it today?" d. "How positive is your self-image?"
Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.
A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? a Tamponade will soon occur. b The renal arteries are involved. c Perfusion to the legs is impaired. d He is bleeding into the abdomen.
Correct Answer: D Rationale: The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patient's nutritional intake? A. Increase intake of liquids at mealtime to stimulate the appetite. B. Serve three large meals per day plus snacks between each meal. C. Avoid the use of liquid protein supplements to encourage eating at mealtime. D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
Correct Answer: D The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to the foods that a patient will eat. Other Rationales: Increasing liquids at meals can cause a patient to feel full faster, leading to eating fewer calories. Eating three large meals isn't possible for a patient on chemotherapy due to the decreased taste sensation. Liquid protein supplements should when needed but they lead to less eating during mealtimes due to feeling of satiation.
A client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell count differential. 2. A large number of WBCs that decrease after the administration of antibiotics. 3. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level. 4. Red blood cells that are larger than normal.
Correct answer is 1. 1. A left shift indicates immature white blood cells are being produced and released into the circulating blood volume. This should be investigated for the malignant process of leukemia.
A diagnosis of Hodgkin's disease is suspected in a 12 year old child seen in a clinic. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test results confirm the diagnosis of Hodgkin's disease? 1. Elevated vanillylmandelic acid urinary levels. 2. The presence of blast cells in the bone marrow. 3. The presence of Epstein-Barr virus in the blood. 4. The presence of Reed-Sternberg cells in the lymph nodes
Correct answer: #4 Hodgkin's disease is a malignancy of the lymph nodes. The presence of giant, multinucleated cells (Reed-sternberg cells) is the classic characteristic of this disease. The presence of blast cells in the bone marrow indicates leukemia. Epstein Barr virus is associated with infectious mononucleosis. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma.
Which strategy can the nurse teach the patient to eliminate the risk of HIV transmission? a. Using sterile equipment to inject drugs b. Cleaning equipment used to inject drugs c. Taking zidovudine (AZT, ZDV, Retrovir) during pregnancy d. Using latex or polyurethane barriers to cover genitalia during sexual contact
Correct answer: a Rationale: Access to sterile equipment is an important risk-elimination tactic. Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment to users in exchange for used equipment. Cleaning equipment before use is a risk-reducing activity. It decreases the risk when equipment is shared, but it takes time, and a person in drug withdrawal may have difficulty cleaning equipment.
The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety. b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility.
Correct answer: b Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.
The patient at highest risk for venous thromboembolism (VTE) is a. a 62-year-old man with spider veins who is having arthroscopic knee surgery. b. a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c. a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d. an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia.
Correct answer: b Rationale: Three important factors (called Virchow's triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these three disorders (see Table 38-8). The 32-year-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives. Note: The likelihood of hypercoagulability of blood is increased in women older than 35 years who use tobacco.
A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return. b. start anticoagulant therapy with IV heparin. c. notify the physician of the change in peripheral perfusion. d. place the bed in reverse Trendelenburg to promote perfusion.
Correct answer: c Rationale: The patient has potentially developed acute arterial ischemia (sudden interruption in the arterial blood supply to the extremity), caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Clinical manifestations of acute arterial ischemia include any or all of the six Ps : pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the physician should be notified immediately
During HIV infection a. the virus replicates mainly in B-cells before spreading to CD4+ T cells. b. infection of monocytes may occur, but antibodies quickly destroy these cells. c. the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells. d. a long period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication
Correct answer: c Rationale: Immune dysfunction in HIV disease is caused predominantly by damage to and destruction of CD4+ T cells (i.e., T helper cells or CD4+ T lymphocytes).
Screening for HIV infection generally involves a. laboratory analysis of blood to detect HIV antigen. b. electrophoretic analysis for HIV antigen in plasma. c. laboratory analysis of blood to detect HIV antibodies. d. analysis of lymph tissues for the presence of HIV RNA.
Correct answer: c Rationale: The most useful screening tests for HIV detect HIV-specific antibodies
What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen? a. "Set up" a drug pillbox for the patient every week. b. Give the patient a video and a brochure to view and read at home. c. Tell the patient that the side effects of the drugs are bad but that they go away after a while. d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances. Correct answer: d Rationale: The best approach to improve adherence to a treatment regimen is to learn about the patient's life and assist with problem solving within the confines of that life.
Correct answer: d Rationale: The best approach to improve adherence to a treatment regimen is to learn about the patient's life and assist with problem solving within the confines of that life.
Which statements accurately describe HIV infection (select all that apply)? a. Untreated HIV infection has a predictable pattern of progression. b. Late chronic HIV infection is called acquired immunodeficiency syndrome (AIDS). c. Untreated HIV infection can remain in the early chronic stage for a decade or more. d. Untreated HIV infection usually remains in the early chronic stage for 1 year or less. e. Opportunistic diseases occur more often when the CD4+ T cell count is high and the viral load is low
Correct answers: a, b, c Rationale: The typical course of untreated HIV infection follows a predictable pattern. However, treatment can significantly alter this pattern, and disease progression is highly individualized. Late chronic infection is another term for acquired immunodeficiency syndrome (AIDS). The median interval between untreated HIV infection and a diagnosis of AIDS is about 11 years.
Which statement about metabolic side effects of ART is true (select all that apply)? a. These are annoying symptoms that are ultimately harmless. b. ART-related body changes include central fat accumulation and peripheral wasting. c. Lipid abnormalities include increases in triglycerides and decreases in high-density cholesterol. d. Insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol. e. Compared to uninfected people, insulin resistance and hyperlipidemia are more difficult to treat in HIV-infected patients
Correct answers: b, c, d Rationale: Some HIV-infected patients, especially those who have been infected and have received ART for a long time, develop a set of metabolic disorders that include changes in body shape (e.g., fat deposits in the abdomen, upper back, and breasts along with fat loss in the arms, legs, and face) as a result of lipodystrophy, hyperlipidemia (i.e., elevated triglyceride levels and decreases in high-density lipoprotein levels), insulin resistance and hyperglycemia, bone disease (e.g., osteoporosis, osteopenia, avascular necrosis), lactic acidosis, and cardiovascular disease.
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1.) Fever and infections. 2.) Nausea and vomiting. 3.) Excessive energy and high platelet counts. 4.) Cervical lymph node enlargement and positive acid-fast bacillus.
Correct: 1. 1. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce WBCs of the number and maturity needed to fight infection (CORRECT). 2. Nausea and vomiting are symptoms related to the treatment of cancer but not to the diagnosis of leukemia (omit #2). 3. The clients are frequently fatigued and have low platelet counts. The platelet count is low as a result of the inability of the bone marrow to produce the needed cells (omit #3). 4. Cervical lymph node enlargement is associated with Hodgkin's lymphoma, and positive acid-fast bacillus is diagnostic for tuberculosis (omit #4).
Which of the following laboratory values could indicate that a child has leukemia? 1. WBCs 32,000/mm3 2. Platelets 300,000/mm3 3. Hemoglobin 15g/dL 4. Blood pH of 7.35
Correct: 1. 1. YES! - A normal WBC count is approximately 4.5 mm3 - 11.0 mm 3. In leukemia a high WBC count is diagnostic and is usually confirmed by a blood smear. 2-4. None of these indicate leukemia,
A child with leukemia is complaining of nausea. A nurse suspects that the nausea is related to the chemotherapy regimen. The nurse, concerned about the child's nutritional status, most appropriately would offer which of the following during this episode of nausea? 1. Cool, clear liquids 2. Low protein foods 3. Low-calorie foods 4. The child's favorite food
Correct: 1. With nausea, cool and clear liquids are better tolerated. Do not offer foods when the child is nauseated so he doesn't associate if with being sick. Support nutrition with oral supplements and foods high in proteins and calories
The client diagnosed with leukemia has central nervous system involvement. Which instructions should the nurse teach? "1.Sleep with the head of the bed elevated to prevent increased intracranial pressure. 2.Take an analgesic medication for pain only when the pain becomes severe. 3.Explain that radiation therapy to the head may result in permanent hair loss. 4.Discuss end-of-life decisions prior to cognitive deterioration"
Correct: 3 1.Sleeping with the head of the bed elevated might relieve some intracranial pressure, but it will not prevent intracranial pressure from occurring. 2.Analgesic medications for clients with cancer are given on a scheduled basis with a fast-acting analgesic administered PRN for break-through pain. 3.Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. If the radiation therapy destroys the hair follicle, the hair will not grow back. 4.Cognitive deterioration does not usually occur"
A 4 yo is admitted for abdominal pain. She has been pale and excessively tired and is bruising easily. On physical exam, lymphadenopathy and hepatosplenomaegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. Which diagnostic study would confirm this diagnosis 1. Platelet count 2. LUmbar puncture 3. bone marrow biopsy 4. wbc count
Correct: 3. 3 leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test is microscopic exam of bone marrow obtained by bone marrow aspirate and biopsy. a lumbar puncture may be done to look for blast cells in the fluid that indicate CNS disease. The wbc count may be normal, high or low in leukemia an altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention? 1.T 99, P 102, R 22, and BP 132/68. 2.Hyperplasia of the gums. 3.Weakness and fatigue. 4.Pain in the left upper quadrant.
Correct: 4 1.These vital signs are not alarming. The vital signs are slightly elevated and indicate monitoring at intervals, but they do not indicate an immediate need. 2.Hyperplasia of the gums is a symptom of myeloid leukemia, but it is not an emergency. 3.Weakness and fatigue are symptoms of the disease and are expected. 4.Pain is expected, but it is a priority, and pain control measures should be implemented.
After a client with a potential diagnosis of leukemia is admitted to the hospital, the nurse should assess for which of the following? (Select all that apply.) A. Reports of fatigue and weakness B. An elevation in the leukocytes especially neutrophils C. Signs of bruising easily D. Recent weight gain
Correct: A, C ANSWER: Reports of fatigue and weakness Signs of bruising easily Rationale: General manifestations of leukemia result from anemia, infection, and bleeding. The client would complain of fatigue and weakness and show signs of bruising. Leukemic cells replace normal hematopoietic elements preventing the formation of mature leukocytes. Neutrophil count would be decreased. Because of an increased metabolism, weight loss may occur.
The mother of a 5-year-old child asks the nurse questions regarding the importance of vigilant use of sunscreen. Which information is most important for the nurse to convey to the mother? A. Appropriate use of sunscreen decreases the risk of skin cancer. B. Repeated exposure to the sun causes premature aging of the skin. C. A child's skin is delicate, and burns easily. D. In addition to causing skin cancer, repeated sun exposure predisposes the child to other forms of cancer.
Correct: A. Appropriate use of sunscreen decreases the risk of skin cancer. While all of the answer choices are correct, recommending the use of sunscreen to decrease the incidence of skin cancer is the best response.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? A. Take the hourly vital signs on a client receiving blood transfusions. B. Monitor the infusion of antineoplastic medications. C. Transcribe the HCP's orders onto the Medication Administration Record. D. Determine the client's response to the therapy.
Correct: A. Explanation: A. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse. B. Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. C. This is the responsibility of the word secretary or the nurse, not the unlicensed personnel. D. This represents the evaluation portion of the nursing process and cannot be delegated.
Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic 2. Morphine, a narcotic analgesic 3. Epogen, a biologic response modifier 4. Gleevec, a genetic blocking agent
Correct: C 1. Because of the ineffective or nonexistent WBCs characteristic of leukemia, the body cannot fight infections, and antibiotics are given to treat infections. 2. Leukemic infiltrations into the organs or the CNS cause pain. Morphine is the drug of choice for most clients with cancer. 3. Epogen is a biologic response modifier that stimulates the bone marrow to produce RBCs. The bone marrow is the area of malignancy in leukemia. Stimulating the bone marrow would be generally ineffective for the desired results and would have the potential to stimulate malignant growth. 4. Gleevec is a drug that specifically works in leukemic cells to block the expression of the BCR-ABL protein, preventing the cells from growing and dividing.
A client, diagnosed with chronic lymphocytic leukemia, is admitted to the hospital for treatment of hemolytic anemia. Which of the following measures, if incorporated into the nursing care plan, would best address the patient's needs? 1. Encourage activities with other patients in the day room. 2. Isolate him from visitors and patients to avoid infection. 3. Provide a diet high in Vitamin C 4. Provide a quiet environment to promote adequate rest.
Correct: D. 1. does not meet need for rest 2. no info given about WBC or reverse isolation, on reverse isolation if neutrophil count is less than 500/mm3 3. needed for wound healing and resistance to infection, not best choice 4. primary problem activity intolerance due to fatigue. Correct
Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic
D The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery
. A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. The nurse explains that the expected outcome of this surgery is a. control of the tumor growth by removal of malignant tissue. b. promotion of better nutrition by relieving the pressure in the stomach. c. relief of pain by cutting sensory nerves in the stomach. d. reduction of the tumor burden to enhance adjuvant therapy.
D Rationale: A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.
19. A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U of NPH insulin at 7:00 AM. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. The most appropriate action by the nurse is to a. save the lunch tray to be provided upon the patient's return to the unit. b. call the diagnostic testing area and ask that a 5% dextrose IV be started. c. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.
D Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. Cognitive Level: Analysis Text Reference: p. 1268 Nursing Process: Implementation NCLEX: Physiological Integrity
23. A patient who has terminal cancer of the liver and is cared for by family members at home tells the nurse, "I have intense pain most of the time now." The nurse recognizes that teaching regarding pain management has been effective when the patient a. uses the ordered opioid pain medication whenever the pain is greater than 5 on a 10-point scale. b. states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief. c. agrees to take the medications by the IV route to improve effectiveness. d. takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
D Rationale: For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route and the oral route is preferred.
27. A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.
D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate. Cognitive Level: Application Text Reference: pp. 1278-1279 Nursing Process: Implementation NCLEX: Physiological Integrity
9. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."
D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. Cognitive Level: Application Text Reference: p. 1268 Nursing Process: Evaluation NCLEX: Physiological Integrity
37. The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. thigh. b. buttock. c. arm. d. abdomen.
D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Implementation NCLEX: Physiological Integrity
8. A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to a. delay eating the noon meal until after the swimming class. b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. c. time the morning insulin injection so that the peak occurs while swimming. d. check glucose level before, during, and after swimming.
D Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
8. A patient with ovarian cancer tells the nurse, "I don't think my husband cares about me anymore. He rarely visits me." On one occasion when the husband was present, he told the nurse he just could not stand to see his wife so ill and never knew what to say to her. An appropriate nursing diagnosis in this situation is a. compromised family coping related to disruption in lifestyle and role changes. b. impaired home maintenance related to perceived role changes. c. risk for caregiver role strain related to burdens of caregiving responsibilities. d. interrupted family processes related to effect of illness on family members.
D Rationale: The data indicate that this diagnosis is most appropriate because the family members are impacted differently by the patient's cancer diagnosis. There are no data to suggest a change in lifestyle or role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities.
5. During a routine health examination, a 30-year-old patient tells the nurse about a family history of colon cancer. The nurse will plan to a. teach the patient about the need for a colonoscopy at age 50. b. ask the patient to bring in a stool specimen to test for occult blood. c. schedule a sigmoidoscopy to provide baseline data about the patient. d. have the patient ask the doctor about specific tests for colon cancer.
D Rationale: The patient is at increased risk and should talk with the health care provider about needed tests, which will depend on factors such as the exact type of family history and any current symptoms. Colonoscopy at age 50 is used to screen for individuals without symptoms or increased risk, but earlier testing may be needed for this patient because of family history. For fecal occult blood testing, patients use a take-home multiple sample method rather than bring one specimen to the clinic. The health care provider will take multiple factors into consideration before determining whether a sigmoidoscopy is needed at age 30.
19. A patient receiving head and neck radiation and systemic chemotherapy has ulcerations over the oral mucosa and tongue and thick, ropey saliva. An appropriate intervention for the nurse to teach the patient is to a. remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. rinse the mouth before and after each meal and at bedtime with a saline solution.
D Rationale: The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.
4. A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease. b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.
D Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. The liver does not produce increased levels of glucose in IFG. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity
2. A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dl (6.7 mmol/L). The nurse will plan to teach the patient about a. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight.
D Rationale: The patient's impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Planning NCLEX: Physiological Integrity
The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? a. prealbumin level b. urine ketone level c. fasting glucose level d. glycosylated hemoglobin level
D - A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.
Multiple drugs are often used in combinations to treat leukemia and lymphoma because: a. there are fewer toxic side effects b. the chance that one drug will be effective is increased c. the drugs are more effective without causing side effects d. the drugs work by different mechanisms to maximize killing of malignant cells
D - Combination therapy is the mainstay of treatment for leukemia. The three purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity to the patient by using multiple drugs with varying toxic effects, and (3) interrupt cell growth at multiple points in the cell cycle.
Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia? a. the patient must receive insulin therapy to prevent ketoacidosis b. the patient has islet cell antibodies that have destroyed the pancreas's ability to produce insulin c. the patient has minimal or absent endogenous insulin secretion and requires daily insulin injections d. the patient may have sufficient endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemic syndrome
D - Hyperosmolar hyperglycemic syndrome (HHS) is a life-threatening syndrome that can occur in a patient with diabetes who is able to produce enough insulin to prevent diabetic ketoacidosis (DKA) but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusion are: a. chills and hemolysis b. leukostasis and neutrophilia c. fluid overload and pulmonary edema d. transmission of cytomegalovirus and fever
D - Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus, hepatitis B and C type 6 (HCV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1 (HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products drastically reduce the risk for viral infections associated with blood transfusions, including CMV.
Because myelodysplastic syndrome arises from the pluripotent hematopoietic stem cell in the bone marrow, laboratory results the nurse would expect to find include a(n): a. excess of T cells b. excess of platelets c. deficiency of granulocytes d. deficiency of all cellular blood components
D - Myelodysplastic syndrome (MDS) commonly manifests as infection and bleeding. It is caused by inadequate numbers of ineffective functioning circulating granulocytes or platelets.
When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find: a. leukopenia b. RBC abnormalities c. decreased hemoglobin d. increased platelet count
D - Splenectomy can have a dramatic effect in increasing peripheral RBC, white blood cell, and platelet counts.
The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control his blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? a. "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." b. "I will go running each day when my blood sugar is too high to bring it back to normal." c. "I will plan to keep my job as a teacher because I get a lot of exercise every school day." d. "I will take a brisk 30-minute walk 5 days per week and do resistance training 3 times a week."
D - The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days per week and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and teaching are light activity, and running is considered vigorous activity.
The patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? a. skin care that will be needed b. method of obtaining the treatment c. gastrointestinal tract effects of treatment d. treatment type and expected side effects
D - The patient with stage favorable prognosis early-stage Hodgkin's lymphoma will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.
When assessing laboratory values on a patient admitted with septicemia, what should the nurse expect to find? a. increased platelets b. decreased red blood cells c. decreased erythrocyte sedimentation rate (ESR) d. increased bands in the white blood cell (WBC) differential (shift to the left)
D - When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Decreased red blood cells indicate anemia. Decreased ESR is not indicative of septicemia.
The nurse would anticipate that a patient with von Willebrand disease undergoing surgery would be treated with administration of vWF and: a. thrombin b. factor VI c. factor VII d. factor VIII
D - von Willebrand disease involves deficiency of the von Willebrand coagulation protein, variable factor VIII deficiencies, and platelet dysfunction. Treatment includes administration of von Willebrand factor and factor VIII.
The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB? A Take the medication with antacids B Double the dosage if a drug dose is forgotten C Increase intake of dairy products D Limit alcohol intake
D) INH and rifampin are hepatotoxic drugs. Clients should be warned to limit intake of alcohol during drug therapy. Both drugs should be taken on an empty stomach. If antacids are needed for GI distress, they should be taken 1 hour before or 2 hours after these drugs are administered. Clients should not double the dosage of these drugs because of their potential toxicity. Clients taking INH should avoid foods that are rich in tyramine, such as cheese and dairy products, or they may develop hypertension.
A client with a positive skin test for TB isn't showing signs of active disease. To help prevent the development of active TB, the client should be treated with isoniazid, 300 mg daily, for how long? A 10 to 14 days B 2 to 4 weeks C 3 to 6 months D 9 to 12 months
D) Because of the increased incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts for 9-12 months. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the best results.
Which of the following family members exposed to TB would be at highest risk for contracting the disease? A 45-year-old mother B 17-year-old daughter C 8-year-old son D 76-year-old grandmother
D) Elderly persons are believed to be at higher risk for contracting TB because of decreased immunocompetence. Other high-risk populations in the US include the urban poor, AIDS, and minority groups.
Which of the following tests is used most often to diagnose angina? A) Chest x-ray B) Echocardiogram C) Cardiac catherization D) 12-lead electrocardiogram (ECG)
D) 12-lead electrocardiogram (ECG) The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition, with variant angina, the ECG shows ST-segment elevation. A chest x-ray will show heart enlargement or signs of heart failure, but isn't used to diagnose angina.
Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? A) Has severe chest pain B) Can identify risks factors for MI C) Agrees to participate in a cardiac rehabilitation walking program D) Can perform personal self-care activities without pain
D) Can perform personal self-care activities without pain By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.
Which diagnostic tool is used to determine the location of myocardial damage for a patient with a myocardial infarction (MI) ? A) CARDIAC CATHETERIZATION B) CARDIAC ENZYMES C) ECHOCARDIAGRAM D) ELECTROCARDIOGRAM (ECG)
D) ELECTROCARDIOGRAM (ECG) ELECTROCARDIOGRAM (ECG) IS THE QUICKEST, MOST ACCURATE AND MOST WIDELY USED TOOL TO DETERMINE THE LOCATION OF A MYOCARDIAL INFARCTION (MI)
Which of the following conditions is the predominant cause of angina? A) Increased preload B) Decreased afterload C) Coronary artery spasm D) Inadequate oxygen supply to the myocardium
D) Inadequate oxygen supply to the myocardium Inadequate oxygen supply to the myocardium is responsible for the pain accompanying angina. Increased preload would be responsible for right-sided heart failure. Decreased afterload causes increased cardiac output. Coronary artery spasm is responsible for variant angina.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because: A) It is uncomfortable for the client, giving a sense of impending doom. B) It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. C) It is almost impossible to convert to a normal sinus rhythm. D) It can develop into ventricular fibrillation at any time.
D) It can develop into ventricular fibrillation at any time. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Client's frequently experience a feeling of impending death. Ventricular tachycardia is treated with antidysrhythmic medications or magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into ventricular defibrillation at any time.
Which of the following symptoms is the most likely origin of pain the client described as knifelike chest pain that increases in intensity with inspiration? A) Cardiac B) Gastrointestinal C) Musculoskeletal D) Pulmonary
D) Pulmonary Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only increases with movement. Cardiac and GI pains don't change with respiration.
What is the primary reason for administering morphine to a client with an MI? A) To sedate the client B) To decrease the client's pain C) To decrease the client's anxiety D) To decrease oxygen demand on the client's heart
D) To decrease oxygen demand on the client's heart Morphine is administered because it decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety while causing sedation, but it isn't primarily given for those reasons
The client asks the nurse, "They say I have cancer. How can they tell if I have Hodgkin'sdisease from a biopsy?" The nurse's answer is based on which scientific rationale? A.Biopsies are nuclear medicine scans that can detect cancer. B.A biopsy is a laboratory test that detects cancer cells. C.It determines which kind of cancer the client has. D.The HCP takes a small piece out of the tumor and looks at the cells.
D-Correct: A biopsy is the removal of cells from a massand examination of the tissue under a microscope to determine if the cells are cancerous. Reed-Sternberg cells are diagnostic for Hodgkin's disease. If these cells are not found in the biopsy, the HCP can rebiopsy to make sure the specimen provided the needed sample or, depending on involvement of the tissue, diagnose a non-Hodgkin's lymphoma
The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A. Veins of the legs B. Lung C. Heart D. Abdominal cavity
D. Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.
A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A. A diagnosis of diabetes treated with insulin and diet B. An exercise regimen of jogging 3 miles four times a week C. A history of cardiac disease D. Advancing age
D. Advancing age Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases. Diabetes is not known to cause lung cancer. Regular exercise is not a risk factor for lung cancer, nor does having cardiac disease predispose a person to lung cancer.
A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A. Explain that this occurs in some clients and is usually permanent. B. Inform the client that a small glass of wine may help her relax. C. Protect the client from infection. D. Allow the client an opportunity to express her feelings.
D. Allow the client an opportunity to express her feelings. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.
Patients with multiple myeloma are encouraged to take in about 3L of fluid daily. The most important rationale for this intervention is: A. Protection of the patient from infection by promoting health skin and mucous membranes B. Prevention of dehydration resulting in nausea and vomiting C. Prevention of GI irritation due to chemotherapeutic agents D. Dilution of calcium and prevention of precipitates of protein in the renal tubules
D. Dilution of calcium and prevention of precipitates of protein in the renal tubules
Which statement about the process of malignant transformation is correct? A. Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. B. Insulin and estrogen enhance the division of an initiated cell during the promotion phase. C. Tumors form when carcinogens invade the gene structure of the cell in the latency phase. D. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage.
D. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage. The promotion phase consists of progression when the blood supply changes from diffusion to TAF. Insulin and estrogen increase cell division. If cell division is halted, mutation of genes does not lead to cancer development in the initiation phase. In the initiation phase, carcinogens invade the DNA of the nucleus of a single cell. A 1-cm tumor consists of 1 billion cells. The latency phase occurs between initiation and tumor formation.
The home health nurse is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment finding is most important to communicate to the transplant team? A. Temperature of 96.6° F B. Reports of joint pain C. Pink and dry oral mucosa D. Palpable lump in the client's axilla
D. Palpable lump in the client's axilla Clients taking immunosuppressive drugs to prevent rejection are at increased risk for the development of cancer; any lump should be reported to the physician. Fever should be reported to the physician, but this client's temperature is normal. It is not necessary to report joint pain to the transplant team; it is not a sign of rejection and is not a complication of transplant. A pink and dry oral mucosa may be a sign of dehydration, but it is not necessary to report this to the transplant team.
An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A. Storing drugs in dark locations at room temperature B. Wearing soft clothing C. Wearing a hat and sunglasses when going outside D. Reducing all direct and indirect sources of light
D. Reducing all direct and indirect sources of light Lighting of all types must be kept to a minimum with clients receiving photodynamic therapy; it can lead to burns of the skin and damage to the eyes because these clients' eyes are sensitive to light. Any drug that the client is prescribed should be considered for its photosensitivity properties; drugs should be stored according to the recommendations, but this is not the primary concern for this client. Clothing must cover the skin to prevent burns from direct or indirect light; texture is not a concern for the client receiving this treatment. The client will be homebound for 1 to 3 months after the treatment and should not go outside.
During physical assessment of a patient, the nurse suspects a chronic, severe iron-deficiency anemia on finding: A. Yellow-tinged sclera B. numbness of the extremities C. gum bleeding and tenderness D. Shiny, smooth tongue
D. Shiny, smooth tongue
A client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure what does the nurse assess first? A. The incision B. Neurologic signs C. Vital signs D. The airway
D. The airway
If hypoglycemic, what should the client do? Example?
Eat simple sugars - Peanut Butter and crackers
A client has a wound infection. What local human response should the nurse expect to identify?
Edema; Chemical mediators increase the permeability of small blood vessels, thereby causing fluid to move into the interstitial compartment, resulting in local edema.
How to draw up insulin:
Ensure blood sugar level and insulin dose. Check Label dose and epiration dates. wash hands. Roll long acting (cloudy - or 20 xs inverting) then swab with alcohol, remove cap and put needle in it and insert air then insert air into clear (short/rapid acting) and keep needle in it and flip vial upside down and draw up amount. Tap to get rid of air, Then draw up the cloudy and tap to remove air and recap needle (cloudy-clear-clear-cloudy) (long acting are not always cloudy)
What does insulin do in the body?
Facilitates glucose uptake into the cells Synthesis of proteins, lipids, and nucleic acids
A postoperative patient has a nursing diagnosis of impaired breathing patternand is fearful that the movement me increased painwhich would be most appropriate for nurse to do
Get the client out of bed have the client do deep breathing and have the client cough every two hours
What changes in the pancreas do we see in aging people?
Glucose intolerance Reduced sensitivity to insulin DIABETES!
You enter a diabetic client's room and they are unconscious. Do you treat this client like he is hypo or hyperglycemic?
HYPO (you're worried about the brain)
When you are SICK or STRESSED, your blood sugar could _________.
INCREASE
What do beta cells release?
Insulin
Abrupt reversal of opioid induced respiratory depression may cause vommittingwhich by the nurse would be most appropriate if this occurs
Maintain patient airway Suctioning the client as needed Turn client to side as needed
A nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?
Neutrophils; Neutrophils are the most numerous leukocytes (white blood cells) and are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis).
A nurse would expect to administer an NSAI DS for what
Osteoarthritis rheumatoid arthritis fever. Primary dysmenorrhea
When discussing effective pain management with nursing student and the teacher would need to discuss barriers they need to overcomewhich of the following would be included
Primary healthcare providers prescribe improper pain management doses Nursing don't administer adequate medicine for pain relief Clients don't report accurate pain levels
A 30-month-old toddler is being evaluated for a ventricular septal defect (VSD). Identify the area where a VSD occurs.
RATIONALE: A VSD is a small hole between the right and left ventricles. It's a common congenital heart defect and accounts for 20% to 30% of all heart lesions.
A preschooler is scheduled to have a Wilms' tumor removed. Identify the area of the urinary system where a Wilms' tumor is located.
RATIONALE: A Wilms' tumor, also known as a nephroblastoma, is a tumor located on the kidney. It's most commonly found in children ages 2 to 4.
A nurse is conducting a physical examination on an infant. Identify the anatomical landmark she should use to measure chest circumference.
RATIONALE: Chest circumference is most accurately measured by placing the measuring tape around the infant's chest with the tape covering the nipples. If measured above or below the nipples, a false measurement is obtained.
A critically ill 4-year-old child is in the pediatric intensive care unit. Telemetry monitoring reveals junctional tachycardia. Identify where this arrhythmia originates.
RATIONALE: In junctional tachycardia, the atrioventricular node fires rapidly.
A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? 1. Always make the toddler wear a seat belt when riding in a car. 2. Make sure all medications are kept in containers with childproof safety caps. 3. Never leave a toddler unattended on a bed. 4. Teach rules of the road for bicycle safety.
RATIONALE: Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers shouldn't be allowed in the road unsupervised.
When teaching school-age children important injury prevention strategies, the nurse must use creativity to gain cooperation because children tend not to comply with: 1. wearing safety apparel (helmets, knee pads, elbow pads). 2. learning to swim. 3. saying "no" when offered illegal or dangerous drugs. 4. learning "stranger danger."
RATIONALE: School-age children are subject to peer pressure, and they would rather not participate in a sport if they must wear safety apparel that provokes taunts from peers. Therefore, the nurse should discuss stylishness, comfort, and social acceptance because these are major determinants of compliance. School-age children like to swim and may work hard to perfect that skill. This age-group will usually listen to reasons for not taking illegal drugs and will adhere to group rules for not tolerating drug use. Regarding stranger danger, this age-group simply needs to be reminded of potential dangers.
A 4-year-old child is brought to the emergency department in cardiac arrest. The staff performs cardiopulmonary resuscitation (CPR). Identify the area where the child's pulse should be checked.
RATIONALE: The carotid artery should be used to check for a pulse when performing CPR on children and adults. The brachial pulse should be used when performing CPR on an infant.
A nurse is feeling the apical impulse of a 28-month-old child. Identify the area where the nurse should assess the apical impulse.
RATIONALE: The heart's apex for a toddler is located at the fourth intercostal space immediately to the left of the midclavicular line. It's one or two intercostal spaces above what's considered normal for the adult because the heart's position in a child of this age is more horizontal and larger in diameter than that of an adult.
A 15-year-old adolescent is admitted to the telemetry unit because of suspected cardiac arrhythmia. A nurse applies five electrodes to his chest and then attaches the lead wires. Identify the area where the nurse should place the chest lead (V1).
RATIONALE: The nurse should place the V1 lead in the fourth intercostal space to the right of the sternum.
A nurse is preparing to give an I.M. injection in the left leg of a 2-year-old child. Identify the area where the nurse should give the injection.
RATIONALE: The vastus lateralis muscle, located in the thigh, is the muscle into which the nurse should administer an I.M. injection in the leg of a toddler. To give an injection into the vastus lateralis muscle, the nurse should divide the distance between the greater trochanter and the knee joints into quadrants. The injection should be given in the center of the upper quadrant.
___ is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Soybeans also contain natural compounds that may reduce LDL (harmful cholesterol) and triglycerides and increase HDL (beneficial cholesterol). The best sources are soy products (tofu, soymilk) or whole soy protein
Soy - remember fiber helps regulate glucose... no quick highs and lows - remember protein
What does glucagon do in the body?
Stimulates hepatic glycogenolysis and gluconeogenesis in presence of hypoglycemia
The cervix of a 26 year old primigravida in labor is 5cm dilated and 75% effaced, and the fetus is at 0 station. The doctor prescribes an epidural regional block. Into which of the following positions should the nurse place the client when the epidural is admin? 1. Lithotomy 2. Supine 3. Prone 4. Lateral
THe client should be placed on her left side or sitting up right, with her shoulders parallel and legs slightly flexed. Her back shouldnt be flexed bc this position increases increases the possibility that the dura may be punctured and the anesthetic will accidentally be given as spinal, not epidural, anesthesia.
DKA has all the usual signs of Type I Diabetes which are:
The 3 p's: hyperglycemia - Polyuria, Polydipsia and Polyphasia
How is the insulin dose determined??
The dose is increased until the blood sugar is normal and until there are no more keytones and glucose in the urine. (which leads to metabolic acidosis)
The client is only comfortable lying on the right side or left side (not on the back or stomach). List at least four potential sites of pressure ulcers the nurse must assess.
These are important areas to assess. Potential ulcer sites for side-lying clients include: 1. Ankles 2. Knees 3. Trochanters 4. Ilia 5. Shoulders 6. Ears
What do you teach someone to do for a coma in home health?
Use honey, jelly, cake icing and put under their tongue, sublingually and follow with complex carbs
A client was infected with TB 10 years ago but never developed the disease. He's now being treated for cancer. The client begins to develop signs of TB. This is known as which of the following types of infection? a) active infection b) primary infection c) super infection d) tertiary infection
a) Some people carry dormant TB infections that may develop into active disease. In addition, primary sites of infection containing TB bacilli may remain inactive for years and then activate when the client's resistance is lowered, as when a client is being treated for cancer. There's no such thing as tertiary infection, and superinfection doesn't apply in this case.
The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? a) "Close lips tightly around the mouthpiece and breathe in deeply and quickly." b) "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." c) "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." d) "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."
a) "Close lips tightly around the mouthpiece and breathe in deeply and quickly." The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.
The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? a) Albuterol (Proventil) b) Salmeterol (Serevent) c) Beclomethasone (Qvar) d) Ipratropium bromide (Atrovent)
a) Albuterol (Proventil) Correct Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide (Atrovent) is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).
A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? a) Anxiety b) Cyanosis c) Bradycardia d) Hypercapnia
a) Anxiety An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.
A male patient with COPD becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? a) Arterial pH 7.26 b) PaCO2 50 mm Hg c) Patient in tripod position d) Increased sputum expectoration
a) Arterial pH 7.26 The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.
When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? a) Increasing dyspnea b) Temperature below 98.6° F c) Decreased sputum production d) Unable to drink 3 L low-sodium fluids
a) Increasing dyspnea The significant clinical manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.
While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? a) Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. b) Use the flow meter each morning after taking medications to evaluate their effectiveness. c) Increase the doses of the long-term control medication if the peak flow numbers decrease. d) Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.
a) Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.
When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? a) Order fruits and fruit juices to be offered between meals. b) Order a high-calorie, high-protein diet with six small meals a day. c) Teach the patient to use frozen meals at home that can be microwaved. d) Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.
a) Order a high-calorie, high-protein diet with six small meals a day. Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with non-protein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.
The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? a) Wheezing becomes louder. b) Cough remains nonproductive. c) Vesicular breath sounds decrease. d) Aerosol bronchodilators stimulate coughing.
a) Wheezing becomes louder. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.
The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? a) Work of breathing b) Fear of suffocation c) Effects of medications d) Anxiety and restlessness
a) Work of breathing When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.
Which statement indicates that the client needs additional instruction about antihypertensive treatment? a. "I will check my blood pressure daily and take my medication when it is over 140/90." b. "I will include rest periods during the day to help me tolerate the fatigue my medicine may cause." c. "I will change my position slowly to prevent feeling dizzy." d. "I will not mow my lawn until I see how this medication makes me feel."
a. "I will check my blood pressure daily and take my medication when it is over 140/90."
A client's serum digoxin level is drawn, and it is 0.4 ng/mL. What is the nurse's priority action? a. Administer ordered dose of digoxin. b. Hold future digoxin doses. c. Administer potassium. d. Call the health care provider.
a. Administer ordered dose of digoxin.
Which is a priority nursing diagnosis for a client taking an antihypertensive medication? a. Alteration in cardiac output related to effects on the sympathetic nervous system b. Knowledge deficit related to medication regimen c. Fatigue related to side effects of medication d. Alteration in comfort related to nonproductive cough
a. Alteration in cardiac output related to effects on the sympathetic nervous system
A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: a. Normal because of the increased blood flow through the leg b. Slightly deteriorating and should be monitored for another hour c. Moderately impaired, and the surgeon should be called. d. Adequate from the arterial approach, but venous complications are arising.
a. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.
What nursing intervention is essential for the client receiving alteplase? a. Assess for reperfusion dysrhythmias. b. Monitor liver enzymes. c. Administer vitamin K if bruising is observed. d. Monitor blood pressure and stop the medication if blood pressure drops below 110 systolic.
a. Assess for reperfusion dysrhythmias.
The nurse explains that which beta blocker category is preferred for treating hypertension? a. Beta1 blocker b. Beta2 blocker c. Beta1 and beta2 blockers d. Beta2 and beta3 blockers
a. Beta1 blocker
A nurse is caring for a client who is taking an angiotensin-converting enzyme inhibitor and develops a dry, nonproductive cough. What is the nurse's priority action? a. Call the health care provider to switch the medication. b. Assess the client for other symptoms of upper respiratory infection. c. Instruct the client to take antitussive medication until the symptoms subside. d. Tell the client that the cough will subside in a few days.
a. Call the health care provider to switch the medication.
Which client assessment would assist the nurse in evaluating therapeutic effects of a calcium channel blocker? a. Client states that she has no chest pain. b. Client states that the swelling in her feet is reduced. c. Client states the she does not feel dizzy. d. Client states that she feels stronger.
a. Client states that she has no chest pain.
When a newly admitted client is placed on heparin, the nurse acknowledges that heparin is effective for preventing new clot formation in clients who have which disorder(s)? (Select all that apply.) a. Coronary thrombosis b. Acute myocardial infarction c. Deep vein thrombosis (DVT) d. Cerebrovascular accident (CVA) (stroke) e. Venous disorders
a. Coronary thrombosis b. Acute myocardial infarction c. Deep vein thrombosis (DVT) d. Cerebrovascular accident (CVA) (stroke) e. Venous disorders
Which assessment indicates a therapeutic effect of mannitol (Osmitrol)? a. Decreased intracranial pressure b. Decreased potassium c. Increased urine osmolality d. Decreased serum osmolality
a. Decreased intracranial pressure
The nurse acknowledges that the first-line drug for treating this client's blood pressure might be which drug? a. Diuretic b. Alpha blocker c. ACE inhibitor d. Alpha/beta blocker
a. Diuretic
A client is taking digoxin (Lanoxin) 0.25 mg and furosemide (Lasix) 40 mg. When the nurse enters the room, the client states, "There are yellow halos around the lights." Which action will the nurse take? a. Evaluate digoxin levels. b. Withhold the furosemide c. Administer potassium. d. Document the findings and reassess in 1 hour.
a. Evaluate digoxin levels.
A nursing instructor is conducting lecture and is reviewing the functions of the female reproductive system. She asks Mark to describe the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH). Mark accurately responds by stating that: a. FSH and LH are released from the anterior pituitary gland. b. FSH and LH are secreted by the corpus luteum of the ovary c. FSH and LH are secreted by the adrenal glands d. FSH and LH stimulate the formation of milk during pregnancy.
a. FSH and LH are released from the anterior pituitary gland. FSH and LH, when stimulated by gonadotropin-releasing hormone from the hypothalamus, are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the graafian follicle, and production of progesterone.
A client who has angina is prescribed nitroglycerin. The nurse reviews which appropriate nursing interventions for nitroglycerin (Select all that apply.) a. Have the client lie down when taking a nitroglycerin sublingual tablet. b. Teach client to repeat taking a tablet in 5 minutes if chest pain persists. c. Apply Transderm-Nitro patch to a hairy area to protect skin from burning. d. Call the health care provider after taking 5 tablets if chest pain persists. e. Warn client against ingesting alcohol while taking nitroglycerin.
a. Have the client lie down when taking a nitroglycerin sublingual tablet. b. Teach client to repeat taking a tablet in 5 minutes if chest pain persists. e. Warn client against ingesting alcohol while taking nitroglycerin.
When a client is taking ezetimibe (Zetia), she asks the nurse how it works. The nurse should explain that Zetia does what? a. Inhibits absorption of dietary cholesterol in the intestines. b. Binds with bile acids in the intestines to reduce LDL levels. c. Inhibits HMG-CoA reductase, which is necessary for cholesterol production in the liver. d. Forms insoluble complexes and reduces circulating cholesterol in blood.
a. Inhibits absorption of dietary cholesterol in the intestines.
The client's serum digoxin level is 3.0 ng/mL. What does the nurse know about this serum digoxin level? a. It is in the high (elevated) range. b. It is in the low (decreased) range. c. It is within the normal range. d. It is in the low average range.
a. It is in the high (elevated) range.
A 62-year-old patient has acquired immunodeficiency syndrome (AIDS), and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? a. The patient has the virus present and can transmit the infection to others. b. The patient is not able to transmit the virus to others through sexual contact. c. The patient will be prescribed lower doses of antiretroviral medications for 2 months. d. The syndrome has been cured, and the patient will be able to discontinue all medications.
a. The patient has the virus present and can transmit the infection to others. In human immunodeficiency virus (HIV) infections, viral loads are reported as real numbers of copies/μL or as undetectable. "Undetectable" indicates that the viral load is lower than the test is able to report. "Undetectable" does not mean that the virus has been eliminated from the body or that the individual can no longer transmit HIV to others.
A client who received heparin begins to bleed, and the physician calls for the antidote. The nurse knows that which is the antidote for heparin? a. protamine sulfate b. vitamin K c. aminocaproic acid d. vitamin C
a. protamine sulfate
The ________ is the site because of it's more rapid and even rate of absorption.
abdomen
The areas of absorption are the __________ (fastest absorption), del____, upper ______ and the ____
abdomen / toid / thigh / hip
Path of DKA is: is it an insulin problem?? What happens to blood sugar?
absent or inadequate insulin / it goes sky high -
When are non-stress and contraction stress test performed?
after 28 weeks
s2 hear sounds are a result of the closures of which valves?
aortic and pulmonic
The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? a) "I will pay less for medication because it will last longer." b) "More of the medication will get down into my lungs to help my breathing." c) "Now I will not need to breathe in as deeply when taking the inhaler medications." d) "This device will make it so much easier and faster to take my inhaled medications."
b) "More of the medication will get down into my lungs to help my breathing." A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.
Which test result identifies that a patient with asthma is responding to treatment? a) An increase in CO2 levels b) A decreased exhaled nitric oxide c) A decrease in white blood cell count d) An increase in serum bicarbonate levels
b) A decreased exhaled nitric oxide Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in the asthma patient.
The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? a) Apical pulse b) Daily weight c) Bowel sounds d) Deep tendon reflexes
b) Daily weight Correct Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes.
The nurse is evaluating if a patient understands how to safely determine whether a metered dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? a) Place it in water to see if it floats. b) Keep track of the number of inhalations used. c) Shake the canister while holding it next to the ear d) Check the indicator line on the side of the canister.
b) Keep track of the number of inhalations used. It is no longer appropriate to see if a canister floats in water or not since this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used. (100 puffs/2 puffs each day = 50 days)
The client asks what the difference is between dalteparin (Fragmin) and heparin. What is the nurse's best response? a. "There is no real difference. Dalteparin is preferred because it is less expensive." b. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." c. "I'm not sure why some health care providers choose dalteparin and some heparin. You should ask your doctor." d. "The only difference is that heparin dosing is based on the client's weight."
b. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding."
Which statement indicates the client understands discharge instructions regarding cholestyramine (Questran)? a. "I will take Questran 1 hour before my other medications." b. "I will increase fiber in my diet." c. "I will weigh myself weekly." d. "I will have my blood pressure checked weekly."
b. "I will increase fiber in my diet."
A client who takes clonidine (Catapres) is to be discharged to home. Which instruction will the nurse include when teaching this client? a. "Your blood pressure should be checked by a health care provider at least once a year." b. "Increasing fluid and fiber in your diet can help prevent the side effect of constipation." c. "Intense exercise or prolonged standing is not a problem with clonidine as it can be with other antihypertensive agents." d. "If you are having difficulty with the common side effect of drooling, notify your health care provider so your dosage can be adjusted."
b. "Increasing fluid and fiber in your diet can help prevent the side effect of constipation."
A client is started on warfarin (Coumadin) therapy while still receiving intravenous heparin. The client questions the nurse about the risk for bleeding. How should the nurse respond? a. "Your concern is valid. I will call the doctor to discontinue the heparin." b. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic." c. "Because of your valve replacement, it is especially important for you to be anticoagulated. The heparin and warfarin together are more effective than one alone." d. "Because you are now up and walking, you have a higher risk of blood clots and therefore need to be on both medications."
b. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic."
A 70-year-old client who is taking several cardiac antidysrhythmic medications has been prescribed simvastatin (Zocor) 80 mg/day. What is essential information for the nurse to teach the client? a. "This dose may lower your cholesterol too much." b. "These factors may put you at higher risk for myopathy." c. "You should not take this drug with cardiac medications." d. "This combination will cause you to have nausea and vomiting."
b. "These factors may put you at higher risk for myopathy."
What is the best information for the nurse to provide to the client who is receiving spironolactone (Aldactone) and furosemide (Lasix) therapy? a. "Moderate doses of two different diuretics are more effective than a large dose of one." b. "This combination promotes diuresis but decreases the risk of hypokalemia." c. "This combination prevents dehydration and hypovolemia." d. "Using two drugs increases the osmolality of plasma and the glomerular filtration rate."
b. "This combination promotes diuresis but decreases the risk of hypokalemia."
A client is prescribed gemfibrozil (Lopid) for treatment of hyperlipidemia type IV. What is important for the nurse to teach the client? a. "Take aspirin before the medication if you experience facial flushing." b. "You may experience headaches with this medication." c. "You will need to have weekly blood drawn to assess for hyperkalemia." d. "Cholesterol levels will need to be assessed daily for one week."
b. "You may experience headaches with this medication."
The nurse plans which intervention to decrease the flushing reaction of niacin? a. Administer niacin with an antacid. b. Administer aspirin 30 minutes before nicotinic acid. c. Administer diphenhydramine hydrochloride (Benadryl) with niacin. d. Apply cold compresses to the head and neck.
b. Administer aspirin 30 minutes before nicotinic acid.
A client has been admitted through the emergency department and requires emergency surgery. The client has been receiving heparin. What nursing intervention is essential? a. Teach the client about the phenytoin. b. Administer protamine sulfate. c. Assess the INR before surgery. d. Administer vitamin K.
b. Administer protamine sulfate.
A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: a. Thrombosis and infection b. Bleeding and infection c. Bleeding and wound dehiscence. d. Wound dehiscence and evisceration.
b. After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client
What instruction should the nurse provide to the client who needs to apply nitroglycerin ointment? a. Use the fingers to spread the ointment evenly over a 3-inch area. b. Apply the ointment to a nonhairy part of the upper torso. c. Massage the ointment into the skin. d. Cover the application paper with ointment before use.
b. Apply the ointment to a nonhairy part of the upper torso.
A client is prescribed losartan (Cozaar). The nurse teaches the client that an angiotensin II receptor blocker (ARB) acts by doing what? a. Inhibiting angiotensin-converting enzyme b. Blocking angiotensin II from AT1 receptors c. Preventing the release of angiotensin I d. Promoting the release of aldosterone
b. Blocking angiotensin II from AT1 receptors
Which assessment finding will alert the nurse to possible toxic effects of amiodarone? a. Heart rate 100 beats per minute b. Crackles in the lungs c. Elevated blood urea nitrogen d. Decreased hemoglobin
b. Crackles in the lungs
A client receiving intravenous nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's priority action? a. Assess the client's lung sounds. b. Decrease the intravenous nitroglycerin by 10 mcg/min. c. Stop the nitroglycerin infusion for 1 hour, and then restart. d. Recheck the client's vital signs in 15 minutes but continue the infusion.
b. Decrease the intravenous nitroglycerin by 10 mcg/min.
A client is taking warfarin 5 mg/day for atrial fibrillation. The client's international normalized ration (INR) is 3.8. The nurse would consider the INR to be what? a. Within normal range b. Elevated INR range c. Low INR range d. Low average INR range
b. Elevated INR range
A client diagnosed with hypercholesterolemia is prescribed lovastatin (Mevacor). The nurse is reviewing the client's history and would contact the health care provider about which of these conditions in the client's history? a. Chronic pulmonary disease b. Hepatic disease c. Leukemia d. Renal disease
b. Hepatic disease
The client has been receiving spironolactone (Aldactone) 50 mg/day for heart failure. The nurse should closely monitor the client for which condition? a. Hypokalemia b. Hyperkalemia c. Hypoglycemia d. Hypermagnesemia
b. Hyperkalemia
A client is taking hydrochlorothiazide 50 mg/day and digoxin 0.25 mg/day. What type of electrolyte imbalance does the nurse expect to occur? a. Hypocalcemia b. Hypokalemia c. Hyperkalemia d. Hypermagnesemia
b. Hypokalemia
A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? a. An acute obstruction in the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency
b. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.
The client taking Methyldopa (Aldomet) has elevated liver function tests. What is the nurse's best action? a. Document the finding and continue care. b. Notify the health care provider. c. Immediately stop the medication. d. Change the client's diet.
b. Notify the health care provider.
A client who is taking warfarin (Coumadin) requests an aspirin for headache relief. What is the nurse's best response? a. Administer 650 mg of acetylsalicylic acid (ASA) and reassess pain in 30 minutes. b. Teach the client of potential drug interactions with anticoagulants. c. Explain to the client that ASA is contraindicated and administer ibuprofen as ordered. d. Explain that the headache is an expected side effect and will subside shortly.
b. Teach the client of potential drug interactions with anticoagulants.
The health care provider is planning to discontinue a client's beta blocker. What instruction should the nurse give the client regarding the beta blocker? a. The beta blocker should be abruptly stopped when another cardiac drug is prescribed. b. The beta blocker should NOT be abruptly stopped; the dose should be tapered down. c. The beta blocker dose should be maintained while taking another antianginal drug. d. Half the beta blocker dose should be taken for the next several weeks.
b. The beta blocker should NOT be abruptly stopped; the dose should be tapered down.
A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: a. Familial tendency toward peripheral vascular disease b. Smoking history c. Recent exposures to allergens d. History of insect bites
b. The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.
The nurse reviews a client's laboratory values and finds a digoxin level of 10 ng/mL and a serum potassium level of 5.9 mEq/L. What is the nurse's primary intervention? a. To administer atropine b. To administer digoxin immune FAB c. To administer epinephrine d. To administer Kayexalate
b. To administer digoxin immune FAB
For the client taking a diuretic, a combination such as triamterene and hydrochlorothiazide may be prescribed. The nurse realizes that this combination is ordered for which purpose? a. To decrease the serum potassium level b. To increase the serum potassium level c. To decrease the glucose level d. To increase the glucose level
b. To increase the serum potassium level
The client is receiving tirofiban (Aggrastat). What is an essential nursing intervention for this client? a. Have protamine sulfate available in case of an overdose. b. Weigh the client before administration. c. Have vitamin K available in case of an overdose. d. Assess intake and output.
b. Weigh the client before administration.
A client is to undergo a coronary angioplasty. The nurse acknowledges that which drug is used primarily for preventing reocclusion of coronary arteries following a coronary angioplasty? a. clopidogrel (Plavix) b. abciximab (ReoPro) c. warfarin (Coumadin) d. streptokinase
b. abciximab (ReoPro)
A client is being changed from an injectable anticoagulant to an oral anticoagulant. Which anticoagulant does the nurse realize is administered orally? a. enoxaparin sodium (Lovenox) b. warfarin (Coumadin) c. bivalirudin (Angiomax) d. lepirudin (Refludan)
b. warfarin (Coumadin)
Which are probable clinical findings in a person with an acute lower extremity VTE (select all that apply)? a.Pallor and coolness of foot and calf b.Mild to moderate calf pain and tenderness c.Grossly diminished or absent pedal pulses d.Unilateral edema and induration of the thigh e.Palpable cord along a superficial varicose vein
b.Mild to moderate calf pain and tenderness d.Unilateral edema and induration of the thigh The patient with lower extremity venous thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature greater than 100.4 F (38 C). If the calf is involved, it may be tender to palpation.
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? a.Sudden shortness of breath and hemoptysis b.Sudden, severe low back pain and bruising along his flank c.Gradually increasing substernal chest pain and diaphoresis d.Sudden, patchy blue mottling on feet and toes and rest pain
b.Sudden, severe low back pain and bruising along his flank The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis (Grey Turner's sign), and hypovolemic shock (tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness).
The patient at highest risk for venous thromboembolism (VTE) is a.a 62-year-old man with spider veins who is having arthroscopic knee surgery. b.a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c.a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d.an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia.
b.a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. Three important factors (called Virchow's triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these three disorders (see Table 38-8). The 32-year-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives. Note: The likelihood of hypercoagulability of blood is increased in women older than 35 years who use tobacco.
With the insulin pump, the pt receives a _____ level of insulin from the pump along with additional insulin as needed with _____, and when/if they have an __________ B/P.
basal / meals / elevated (In a person with diabetes, giving a constant low level amount of insulin via insulin pump mimics this normal phenomenon)
Is the angle of Louie above or below the sternum notch?
below
When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? a) Smoking causes a hoarse voice. b) Cough will become non productive. c) Decreased alveolar macrophage function d) Sense of smell is decreased with smoking.
c) Decreased alveolar macrophage function The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection.
The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which finding? a) Absence of dyspnea b) Improved mental status c) Effective and productive coughing d) PaO2 within normal range for the patient
c) Effective and productive coughing Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.
The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? a) Allow time to calm the patient. b) Observe for signs of diaphoresis. c) Evaluate the use of intercostal muscles. d) Monitor the patient for bilateral chest expansion.
c) Evaluate the use of intercostal muscles. The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.
Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? a) Acute respiratory failure b) Secondary respiratory infection c) Fluid volume excess resulting from cor pulmonale d) Pulmonary edema caused by left-sided heart failure
c) Fluid volume excess resulting from cor pulmonale Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.
The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium (Atrovent) after noting which assessment finding? a) Decreased respiratory rate b) Increased respiratory rate c) Increased peak flow readings d) Decreased sputum production
c) Increased peak flow readings Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates (PEFRs).
During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? a) Laryngospasm b) Pulmonary edema c) Narrowing of the airway d) Overdistention of the alveoli
c) Narrowing of the airway Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing
When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? a) Fat soluble vitamins and dietary salt should be avoided. b) Insulin may be needed with a diabetic diet if diabetes mellitus develops. c) Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. d) Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.
c) Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. The patient must take pancreatic enzymes before each meal and snack and adequate fat, calories, protein, and vitamins should be eaten. Fat-soluble vitamins are needed because they are malabsorbed with the excess mucus in the gastrointestinal system. Insulin may be needed, but there is no longer a diabetic diet, and this is not priority information at this time. DIOS develops in the terminal ileum and is treated with balanced polyethylene glycol electrolyte solution (MiraLAX) to thin bowel contents.
The nurse teaches pursed lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? a) Loosening secretions so that they may be coughed up more easily b) Promoting maximal inhalation for better oxygenation of the lungs c) Preventing bronchial collapse and air trapping in the lungs during exhalation d) Increasing the respiratory rate and giving the patient control of respiratory patterns
c) Preventing bronchial collapse and air trapping in the lungs during exhalation The purpose of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.
The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? a) IV fluids b) Biofeedback therapy c) Systemic corticosteroids d) Pulmonary function testing
c) Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used, but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.
A client is receiving warfarin (Coumadin) for a chronic condition. Which client statement requires immediate action by the nurse? a. "I will avoid contact sports." b. "I will take my medication in the early evening each day." c. "I will increase dark-green, leafy vegetables in my diet." d. "I will contact my health care provider if I develop excessive bruising."
c. "I will increase dark-green, leafy vegetables in my diet."
Which client would the nurse need to assess first if the client is receiving mannitol (Osmitrol)? a. A 67-year-old client with type 1 diabetes mellitus b. A 21-year-old client with a head injury c. A 47-year-old client with anuria d. A 55-year-old client receiving cisplatin to treat ovarian cancer
c. A 47-year-old client with anuria
A nurse is caring for a client receiving acetazolamide (Diamox). Which assessment finding will require immediate nursing intervention? a. A decrease in bicarbonate level b. An increase in urinary output c. A decrease in arterial pH d. An increase in PaO2
c. A decrease in arterial pH
The nurse is assessing a client who is taking furosemide (Lasix). The client's potassium level is 3.4 mEq/L, chloride is 90 mmol/L, and sodium is 140 mEq/L. What is the nurse's primary intervention? a. Mix 40 mEq of potassium in 250 mL D5W and infuse rapidly. b. Administer Kayexalate. c. Administer 2 mEq potassium chloride per kilogram per day IV. d. Administer PhosLo, two tablets three times per day.
c. Administer 2 mEq potassium chloride per kilogram per day IV.
A nurse is preparing to administer enoxaparin sodium (Lovenox) to a client for prevention of deep vein thrombosis. What is an essential nursing intervention? a. Draw up the medication in a syringe with a 22-gauge, 1-½ inch needle. b. Utilize the Z-track method to inject the medication. c. Administer the medication into subcutaneous tissue. d. Rub the administration site after injecting.
c. Administer the medication into subcutaneous tissue.
What will the nurse instruct the client to do to prevent the development of tolerance to nitroglycerin? a. Apply the nitroglycerin patch every other day. b. Switch to sublingual nitroglycerin when the client's systolic blood pressure elevates to more than 140 mm Hg. c. Apply the nitroglycerin patch for 14 hours and remove it for 10 hours at night. d. Use the nitroglycerin patch for acute episodes of angina only.
c. Apply the nitroglycerin patch for 14 hours and remove it for 10 hours at night.
Before the nurse administers isosorbide mononitrate (Imdur), what is a priority nursing assessment? a. Assess serum electrolytes. b. Measure blood urea nitrogen and creatinine. c. Assess blood pressure. d. Monitor level of consciousness.
c. Assess blood pressure.
Which intervention will the nurse perform when monitoring a client receiving triamterene (Dyrenium)? a. Assess urinary output hourly. b. Monitor for side effect of hypoglycemia. c. Assess potassium levels. d. Monitor for Hypernatremia.
c. Assess potassium levels.
The nurse is aware that which group(s) of antihypertensive drugs are less effective in African-American clients? a. Diuretics b. Calcium channel blockers and vasodilators c. Beta blockers and ACE inhibitors d. Alpha blockers
c. Beta blockers and ACE inhibitors
The nurse is teaching a client about clopidogrel (Plavix). What is important information to include? a. Constipation may occur. b. Hypotension may occur. c. Bleeding may increase when taken with aspirin. d. Normal dose is 25 mg tablet per day.
c. Bleeding may increase when taken with aspirin.
Varicose veins can cause changes in what component of Virchow's triad? a. Blood coagulability b. Vessel walls c. Blood flow d. Blood viscosity
c. Blood flow
The nurse reviews the history for a client taking atorvastatin (Lipitor). What will the nurse act on immediately? a. Client takes medications with grape juice. b. Client takes herbal therapy including kava kava. c. Client is on oral contraceptives. d. Client was started on penicillin for a respiratory infection.
c. Client is on oral contraceptives.
Which of the following characteristics is typical of the pain associated with DVT? a. Dull ache b. No pain c. Sudden onset d. Tingling
c. DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain.
The nurse acknowledges that beta blockers are as effective as antianginals because they do what? a. Increase oxygen to the systemic circulation. b. Maintain heart rate and blood pressure. c. Decrease heart rate and decrease myocardial contractility. d. Decrease heart rate and increase myocardial contractility.
c. Decrease heart rate and decrease myocardial contractility.
A client with hyperaldosteronism is prescribed spironolactone (Aldactone). What assessment finding would the nurse evaluate as a positive outcome? a. Decreased potassium level b. Decreased crackles in the lung bases c. Decreased aldosterone d. Decreased ankle edema
c. Decreased aldosterone
A client taking prazosin has a blood pressure of 140/90. The client is complaining of swollen feet. What is the nurse's best action? a. Hold the medication. b. Call the health care provider. c. Determine the client's history. d. Weigh the client.
c. Determine the client's history.
A nurse is caring for a client who has been started on ibutilide (Corvert). Which assessment is a priority for this client? a. Blood pressure measurement b. BUN and creatinine c. ECG d. Lung sounds
c. ECG
A client taking spironolactone (Aldactone) has been taught about the therapy. Which menu selection indicates that the client understands teaching related to this medication? a. Apricots b. Bananas c. Fish d. Strawberries
c. Fish
A client has heart failure and is prescribed Lasix. The nurse is aware that furosemide (Lasix) is what kind of drug? a. Thiazide diuretic b. Osmotic diuretic c. High-ceiling (loop) diuretic d. Potassium-sparing diuretic
c. High-ceiling (loop) diuretic
What would cause the same client's electrolyte imbalance? a. High dose of digoxin b. Digoxin taken daily c. Hydrochlorothiazide d. Low dose of hydrochlorothiaizde
c. Hydrochlorothiazide
A client has a serum cholesterol level of 265 mg/dL, triglyceride level of 235 mg/dL, and LDL of 180 mg/dL. What do these serum levels indicate? a. Hypolipidemia b. Normolipidemia c. Hyperlipidemia d. Alipidemia
c. Hyperlipidemia
A calcium channel blocker has been ordered for a client. Which condition in the client's history is a contraindication to this medication? a. Hypokalemia b. Dysrhythmias c. Hypotension d. Increased intracranial pressure
c. Hypotension
The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a 56-year-old man with acquired immunodeficiency syndrome (AIDS). What laboratory study result indicates the medications have been effective? a. Increased viral load b. Decreased neutrophil count c. Increased CD4+ T cell count d. Decreased white blood cell count
c. Increased CD4+ T cell count Antiretroviral therapy is effective if there are decreased viral loads and increased CD4+ T cell counts.
A client with acute pulmonary edema receives furosemide (Lasix). What assessment finding indicates that the intervention is working? a. Potassium level decreased from 4.5 to 3.5 mEq/L. b. Crackles auscultated in the bases. c. Lungs clear. d. Output 30 mL/hr.
c. Lungs clear.
A client is to begin treatment for short-term management of heart failure with milrinone lactate (Primacor). What is the priority nursing action? a. Administer digoxin via IV infusion with the Primacor. b. Administer Lasix (furosemide) via IV infusion after the Primacor. c. Monitor blood pressure continuously. d. Maintain an infusion of lactated Ringers with Primacor infusion.
c. Monitor blood pressure continuously.
A client is prescribed ezetimibe (Zetia). Which assessment finding will require immediate action by the nurse? a. Headache. b. Slight nausea. c. Muscle pain. d. Fatigue.
c. Muscle pain.
A client is admitted to the emergency department with paroxysmal supraventricular tachycardia. What intervention is the nurse's priority? a. Administration of digoxin IV push b. Administration of oxygen, 2 lpm c. Rapid IV bolus of Adenosine (Adenocard) d. Instructing client to "bear down"
c. Rapid IV bolus of Adenosine (Adenocard)
A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension
c. Stage 1 hypertension
Which client will the nurse assess first? a. The client who has been on beta blockers for 1 day. b. The client who is on a beta blocker and a thiazide diuretic. c. The client who has stopped taking a beta blocker due to cost. d. The client who is taking a beta blocker and Lasix (furosemide).
c. The client who has stopped taking a beta blocker due to cost.
A nurse admits a client diagnosed with pneumonia. The client has a history of chronic renal insufficiency, and the health care provider orders furosemide (Lasix) 40 mg twice a day. What is most important to include in the teaching plan for this client? a. That the medication will have to be monitored very carefully owing to the client's diagnosis of pneumonia. b. The fact that Lasix has been proven to decrease symptoms with pneumonia. c. The fact that Lasix has shown efficacy in treating persons with renal insufficiency. d. That the medication will need to be given at a higher than normal dose owing to the client's medical problems.
c. The fact that Lasix has shown efficacy in treating persons with renal insufficiency.
A client is admitted to the emergency department with an acute myocardial infarction. Which drug category does the nurse expect to be given to the client early for the prevention of tissue necrosis following blood clot blockage in a coronary or cerebral artery? a. Anticoagulant agent b. Antiplatelet agent c. Thrombolytic agent d. Low-molecular-weight heparin (LMWH)
c. Thrombolytic agent
The beta blocker acebutolol (Sectral) is prescribed for dysrhythmias. The nurse knows that what is the primary purpose of the drug? a. To increase the beta1 and beta2 receptors in the cardiac tissues b. To increase the flow of oxygen to the cardiac tissues c. To block the beta1-adrenergic receptors in the cardiac tissues d. To block the beta2-adrenergic receptors in the cardiac tissues
c. To block the beta1-adrenergic receptors in the cardiac tissues
A nurse is caring for a client with elevated triglyceride levels who is unresponsive to HMG-CoA reductase inhibitors. What medication will the nurse administer? a. cholestyramine (Questran) b. colestipol (Colestid) c. gemfibrozil (Lopid) d. simvastatin (Zocor)
c. gemfibrozil (Lopid)
A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are a.weight and diet. b.activity level and diet. c.tobacco use and high blood pressure. d.sedentary lifestyle and high blood pressure.
c. tobacco use and high blood pressure Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.
Lantus is ________ and is considered _______ acting insulin.
clear and long
MENCONIUM
collects in the GI tract during gestation and is initially STERILE greenish black bc of occult blood and is viscous stools of breast fed neonates - are loose golden yellow after the transition to extrauterine life stools of formula fed babies are - typically soft and pale yellow after feeding's well established
Withdraw clear or regular insulin first before cloudy insulin to prevent ___________ the clear insulin with the cloudy insulin
contaminating
A client with primary TB infection can expect to develop which of the following conditions? a) Active TB within 2 weeks b) Active TB within 1 month c) A fever that requires hospitalization d) A positive skin test
d) A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, in many cases because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.
A patient has been receiving oxygen per nasal cannula while hospitalized for COPD. The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? a) "Long-term home oxygen therapy should be used to prevent respiratory failure." b) "Oxygen will not be needed until or unless you are in the terminal stages of this disease." c) "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." d) "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."
d) "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia." Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered
Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? a) Supine b) Lithotomy c) High Fowler's d) Reverse Trendelenburg
d) High Fowler's The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.
Before discharge, the nurse discusses activity levels with a 61-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? a) Slightly increase activity over the current level. b) Swim for 10 min/day, gradually increasing to 30 min/day. c) Limit exercise to activities of daily living to conserve energy. d) Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.
d) Walk for 20 min/day, keeping the pulse rate less than 130 beats/min. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 - patient's age).
Which statement indicates to the nurse that the client understands sublingual nitroglycerin medication instructions? a. "I will take up to five doses every 3 minutes for chest pain." b. "I can chew the tablet for the quickest effect." c. "I will keep the tablets locked in a safe place until I need them." d. "I should sit or lie down after I take a nitroglycerin tablet to prevent dizziness."
d. "I should sit or lie down after I take a nitroglycerin tablet to prevent dizziness."
The nurse evaluates that the client understood discharge teaching regarding warfarin (Coumadin) based on which statement? a. "I will double my dose if I forget to take it the day before." b. "I should keep taking ibuprofen for my arthritis." c. "I should decrease the dose if I start bruising easily." d. "I should use a soft toothbrush for dental hygiene."
d. "I should use a soft toothbrush for dental hygiene."
Which statement made by the client indicates understanding about discharge instructions on antihyperlipidemic medications? a. "Antihyperlipidemic medications will replace the other interventions I have been doing to try to decrease my cholesterol." b. "It is important to double my dose if I miss one in order to maintain therapeutic blood levels." c. "I will stop taking the medication if it causes nausea and vomiting." d. "I will continue my exercise program to help increase my high-density lipoprotein serum levels."
d. "I will continue my exercise program to help increase my high-density lipoprotein serum levels."
What statement is the most important for the nurse to include in the teaching plan for a client who has started on a transdermal nitroglycerin patch? a. "This medication works faster than sublingual nitroglycerin works." b. "This medication is the strongest of any nitroglycerin preparation available." c. "This medication should be used only when you are experiencing chest pain." d. "This medication will work for 24 hours and you will need to change the patch daily."
d. "This medication will work for 24 hours and you will need to change the patch daily."
A client is prescribed Thalitone (chlorthalidone). What is the most important information the nurse should teach the client? a. "Do not drink more than 10 ounces of fluid a day while on this medication." b. "Take this medication on an empty stomach." c. "Take this medication before bed each night." d. "Wear protective clothing and sunscreen while on this medication."
d. "Wear protective clothing and sunscreen while on this medication."
A nurse is monitoring a client with angina for therapeutic effects of nitroglycerin. Which assessment finding indicates that the nitroglycerin has been effective? a. Blood pressure 120/80 mm Hg b. Heart rate 70 beats per minute c. ECG without evidence of ST changes d. Client stating that pain is 0 out of 10
d. Client stating that pain is 0 out of 10
A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? a. Cough, diarrhea, headaches, blurred vision, muscle fatigue d. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy c. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea
d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lympadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer).
The nurse is caring for a client with hypertension who is prescribed Clonidine transdermal preparation. What is the correct information to teach this client? a. Change the patch daily at the same time. b. Remove the patch before taking a shower or bath. c. Do not take other antihypertensive medications while on this patch. d. Get up slowly from a sitting to a standing position.
d. Get up slowly from a sitting to a standing position.
A client is taking lovastatin (Mevacor). Which serum level is most important for the nurse to monitor? a. Blood urea nitrogen b. Complete blood count c. Cardiac enzymes d. Liver enzymes
d. Liver enzymes
The nurse is assessing the client for possible evidence of digitalis toxicity. The nurse acknowledges that which is included in the signs and symptoms for digitalis toxicity? a. Pulse (heart) rate of 100 beats/min b. Pulse of 72 with an irregular rate c. Pulse greater than 60 beats/min and irregular rate d. Pulse below 60 beats/min and irregular rate
d. Pulse below 60 beats/min and irregular rate
The nurse is providing postoperative care for a 30-year-old female patient after an appendectomy. The patient has tested positive for human immunodeficiency virus (HIV). What type of precautions should the nurse observe to prevent the transmission of this disease? a. Droplet precautions b. Contact precautions c. Airborne precautions d. Standard precautions
d. Standard precautions Standard precautions are indicated for prevention of transmission of HIV to the health care worker. HIV is not transmitted by casual contact or respiratory droplets. HIV may be transmitted through sexual intercourse with an infected partner, exposure to HIV-infected blood or blood products, and perinatal transmission during pregnancy, at delivery, or though breastfeeding.
A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: a. Has a pale colored base b. Is deep, with even edges c. Has little granulation tissue d. Has brown pigmentation around it.
d. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due to tissue malnutrition; and thus us an arterial problem)
The nurse is reviewing a medication history on a client taking an ACE inhibitor. The nurse plans to contact the health care provider if the client is also taking which medication? a. docusate sodium (Colace) b. furosemide (Lasix) c. morphine sulfate d. spironolactone (Aldactone)
d. spironolactone (Aldactone)
What should the client do pre-exercise to prevent hypoglycemia?
eat something
The term that refers to the progressive thinning and shortening of the cervix?
effacement (0-100)%
How does the ultrasound estimate the fetal age?
from head measurements
If you needed to give heparin or levenox - which should you NOT give?
lovenox
When insulin is at it's peak, the blood sugar is _____
lowest - because the insulin is working and getting the glucose into the cell - so serum glucose is lowest.
Pressure may be applied over the site but do not _______ after injection as this will alter absorption rate.
message
On the 2nd PP day, a client complains that shes urinating more than when she was pregnant. Which is the primary cause of increased urinary output post delivery? 1. postpartum diuresis
occurs as the body starts to reduce the extracellular fluid volume that increased during preg renal plasma flow and GFR also increase slightly until approx 1 week PP Renal malfunctioning is more likely to decrease urinary output, not increase it increase PP fluid intake and breast feeding arent major causes of PP diuresis
Hypoglycemics agents work by stimulating the _________ to make __________.
pancreas / insulin
what is the only type of insulin you can give IV?
regular
It is important to ______ sites of insulin injection in order to avoid tissue damage.
rotate
Exersize the ______ time and amount daily
same
What is an example of something a hypoglycemic would eat as _________ sugars?
simple / PB and crackers
With DKA tx: give hourly: ____, _____, and ________________
sugar, K+ and output
Evaporation Heat Loss
the loss of heat that occurs when a liquid is converted to a vapor
At 20 cm what region is the fundus?
umbilicus
If DBic than B/P goes _______ when stressed. Insulin has to be adjusted or they can go into _______. Always think _______ with illness on the NCLEX.
up / DKA / DKA
Extreme blood sugar can make ___________ damage
vascular
Role of vitamin k in a neonate
vitamin K, deficient in the neonate, is needed to activate clotting factors II,IV,IX and X In the event of trauma, the neonate would be at risk for EXCESSIVE BLEEDING vitamin k doesnt assist the gut to mature but the gut PRODUCES vitamin K once maturity is achieved
Change injection area until the _____ site has been used.
whole
