Fundamentals Exam 1

Which nursing theorist addressed self-care deficits in her nursing theory?

Dorothea Orem Explanation: Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps the client balance the changes that occur as he constantly evolves.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should:

Handle TPN using strict aseptic technique. Explanation: TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which of the following problems should the nurse address first?

Impaired gas exchange. Correct Explanation: Emboli obstruct blood flow, leading to a decreased perfusion of the lung tissue. Because of the decreased perfusion, a ventilation-perfusion mismatch occurs, causing hypoxemia to develop. Arterial blood gas analysis typically will indicate hypoxemia and hypocapnia. A priority objective in the treatment of pulmonary emboli is maintaining adequate oxygenation. A nonproductive cough and activity intolerance do not indicate impaired gas exchange. The client does not demonstrate an ineffective breathing pattern; rather, the problem of impaired gas exchange is caused by the inability of blood to flow through the lung tissue.

A child with asthma continues to have a heart rate of 160 beats/minute and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which of the following findings would indicate that the nebulizer treatment has been effective?

Increase in peak expiratory flow rate. Explanation: The best indicator of the effectiveness of the albuterol is an increase in peak expiratory flow rate. Albuterol, a bronchodilator, opens and relaxes the airways, allowing a greater exchange of air, which is reflected as a higher peak expiratory flow rate. Pulse oximetry reflects how well the client is oxygenating: the higher the reading, the better the client's oxygenation. Typically, a pulse oximeter reading of 95% or greater is the goal. Furthermore, a pulse oximeter reading of 91% is meaningless unless previous readings are available for comparison. As the airways open, the child should begin to have a productive cough. Wheezing may or may not be a reliable indicator for determining the effectiveness of the albuterol treatment. The nebulizer treatment may increase wheezing by opening the airways enough so that air can travel through the excessively mucus-filled bronchioles. Because this child is still experiencing respiratory distress, some wheezing would be expected. However, wheezing in a child with asthma who is in acute distress may indicate an improvement, demonstrating the movement of air through the airways that were previously blocked.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest where there was an impact on the steering wheel. He also has a compound fracture of his right tibia and fibula and multiple lacerations and contusions. The primary goal at this point is to:

Maintain adequate oxygenation. Explanation: Blunt chest trauma can lead to respiratory failure. Maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation, as is maintaining adequate circulatory volume.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:

Meet the fluid and nutritional needs of the client. Correct Explanation: The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fluid and nutritional needs of the client as the surgical site is healing. The feeding tube does help prevent aspiration by preventing ingested fluid from leaking through the wound into the trachea before healing occurs; however, the primary rationale is to meet the client's nutritional and fluid needs. A tracheoesophageal fistula is a rare complication of total laryngectomy and may occur if radiation therapy has compromised wound healing. A feeding tube does not help maintain an open airway

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which of the following types of diet should the nurse discuss?

Regular diet. Explanation: For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?

Regular. Explanation: Dietary management following rehydration for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:

enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include:

ground beef patties. Explanation: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which of the following foods? Select all that apply.

• Cooked dry beans. • Peanut butter. • Yogurt Explanation: Yogurt, dry beans, and peanut butter all contain protein in amounts that make them good sources of protein for the child. Bacon is high in fat; an apple is a carbohydrate.

A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs?

Brown rice. Explanation: Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.

A client is recovering from an infected abdominal wound. Which of the following foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

Chicken and orange slices. Explanation: Protein and vitamin C are particularly important in promoting wound healing and recovery from infection. A diet high in carbohydrates is also essential. Because the client with an infection commonly does not feel like eating, it is important that what he is encouraged to eat should be nutritious. Chicken and orange slices would help meet the client's protein and vitamin needs. A meal of cheeseburger and fries or cheese omelet and bacon is high in fat and low in vitamins. Gelatin salad and tea contain minimal nutrients.

An elderly client is admitted with fatigue and weight loss. The nurse anticpates that which laboratory test will be ordered as the most important indicator of malnutrition?

Albumin level Correct Explanation: Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill?

A 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused. Correct Explanation: The 60-year-old woman is acting in a way that worsens her physical and mental condition because she does not want to be sick. The 8-year-old child is acting normally for someone his age who is unexpectedly hospitalized. The cooperation demonstrated by the client with lupus and the client who had a myocardial infarction indicates a level of acceptance of their illnesses and of their role as being ill.

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?

A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line. Correct Explanation: The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if he goes into atrial fibrillation, but he isn't a priority at this time.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?

Decreased oxygenation of the blood. Correct Explanation: A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. Decreased cardiac output may be a comorbid condition in some clients with pneumonia; however, it is not the cause of cyanosis. Pleural effusions are a potential complication of pneumonia but are not the primary cause of decreased oxygenation. Inadequate peripheral circulation is also not the cause of the cyanosis that develops with bacterial pneumonia.

An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority?

Establishing an airway. Correct Explanation: The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established. (less)

The nurse observes that a client who has received midazolam for local anesthesia is having shallow respirations. The nurse should:

Have respiratory resuscitation equipment in the room. Explanation: The nurse does not administer naloxone because naloxone is the antidote for morphine, not midazolam. The benzodiazepine-receptor antagonist for midazolam is flumazenil. The nurse can promote oxygenation by encouraging deep breathing and administering oxygen. Resuscitation equipment should be accessible if needed.

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?

Primary prevention Explanation: Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health as a result of others' activities without doing anything themselves.

The nurse is teaching a client with emphysema how to do pursed-lip breathing. What is the expected outcome of using pursed-lip breathing?

Prolonged exhalation. Explanation: The primary reason for instructing the client with emphysema about how to pursed-lip breathe is to prolong exhalation. Prolonging exhalation helps to prevent bronchiolar collapse and the trapping of air. It does not directly prevent respiratory infection. Because pursed-lip breathing affects the expiratory phase of the respiratory cycle, it does not affect oxygenation. It may decrease shortness of breath, but this is not the primary reason for the technique.

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)?

Providing a low-calorie diet Correct Explanation: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?

Remain in a side-lying position with the head elevated. Explanation: The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.

A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute Correct Explanation: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners?

Respiratory therapist. Correct Explanation: A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely to provide needed interventions at this time.

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician prescriptions include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 ml/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should first:

The first action is to increase the oxygen flow rate from 2 to 4 L/minute to help ensure adequate oxygenation for the client. Although it is important to notify the physician for additional orders and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client's cardiopulmonary system. It would be appropriate to reassure the client while these other interventions are occurring.

Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?

To promote carbon dioxide elimination. Correct Explanation: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

Which of the following is most helpful in determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation. Correct Explanation: A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy. Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need. Fatigue may be due to other factors besides oxygenation levels. Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need.

Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following problems should receive the highest priority during the acute phase?

neffective breathing pattern related to neuromuscular impairment. Explanation: Ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the child's ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on the child's ability to maintain respirations. Risk for infection related to an altered immune system is not involved with Guillain-Barré syndrome. Although impaired swallowing and incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching?

"Today I can have apple juice, chicken broth, and vanilla ice cream." Explanation: A bland, full-liquid diet may include some fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as orange juice, coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered. Correct Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first:

Administer oxygen. Correct Explanation: Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

An inhaled beta2-adrenergic agonist Correct Explanation: An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.

The client has sore nares while a nasogastric (NG) tube is in place. Which of the following nursing measures would be most appropriate to help alleviate the client's discomfort?

Apply a water-soluble lubricant to the nares. Explanation: Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube is in place. Repositioning the tube does not eliminate the possibility of irritating the nares. Irrigating the tube with a cool solution or changing positions will not relieve the local irritation from the NG tube.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Auscultating the lungs for bilateral breath sounds Correct Explanation: For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans, hamburger, and milk Correct Explanation: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

Which of the following theories of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics. Explanation: Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology, utilitarianism, and principle-based ethics each prioritize goals and principles that exist beyond the particularities of the nurse-client relationship.

On the first day after surgery, a client has been breathing room air. Vital signs are normal and O2 saturation is 89%. The nurse should first:

Deep breathing and coughing in postoperative clients help increase lung expansion and prevent the accumulation of secretions. An O2 saturation of 89% is not unexpected or an emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89%, but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the physician prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breathe first, in an attempt to improve oxygenation and saturation.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Deficient fluid volume Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

An elderly woman has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO." Based on this order, what action should the nurse take?

Ensure that the client does not eat or drink anything. Correct Explanation: The abbreviation "NPO" denotes that the client should take nothing by mouth. It is irrelevant to insurance status, oxygenation, or gastric intubation.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

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

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal suctioning Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be which of the following?

Enhance myocardial oxygenation Correct Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.

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?

Heart rate less than 60 beats/minute Explanation: 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.

When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications?

Infection. Correct Explanation: Infection is the greatest concern to the nurse. Infection occurs more frequently because of the number of procedures performed on clients that require this therapy and people they come in contact with in the hospital. Infection can be reduced if proper infection control techniques are used and human contact is reduced. Deficiencies and toxicities of nutrients are rare because of the use of standard protocols and orders for TPN formulas. Hyperglycemia can occur with TPN administration; however, all clients receiving TPN have their serum glucose concentration monitored frequently, and the hyperglycemia can easily be managed by adding insulin to the TPN solution. An infection is a much more serious complication.

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

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

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize?

Lean meats and low-fat milk Explanation: Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection?

Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?

Monitor the appearance, size, and number of stools. Explanation: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy.

Which guidelines define and regulate what the nurse may and may not do as a professional?

Nurse practice act Correct Explanation: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Nutrition support and orthotics Correct Explanation: Nutrition support should be consulted to evaluate the client's caloric needs for wound healing. Orthotics should also be consulted for specialized footwear designed to keep pressure off the client's heel. Physical therapy is necessary to help the client achieve the highest level of functioning; however, a respiratory consult isn't necessary unless the client has a coexisting respiratory problem. Occupational therapy may be helpful to assist with activities of daily living, but an infectious disease consult isn't necessary unless the client has a coexisting infection. A plastic surgery consult may be necessary if debridement or grafting is likely, but nothing indicates that a cardiology consult is needed.

he parents of a 15-year-old female with a history of disordered eating are concerned about her loss of 24 lb (10.9 kg) during the previous month. The nurse tells the parents that she'll give their daughter a comprehensive examination and make appropriate referrals. Which initial referrals should the nurse make? Select all that apply.

Nutritional consult • Psychiatric evaluation Explanation: A nurse must assess a client with disordered eating and create a care plan to stabilize body weight and prevent further weight loss. The nutritional consult helps determine nutritional needs to maintain body weight. A psychiatric evaluation establishes the baseline for a care plan to address the client's emotional needs, process the client's feelings and experiences, develop effective coping skills, and develop a realistic body image and positive self-image. After the adolescent's body weight stabilizes, she should have a dental assessment to identify dental problems resulting from malnutrition or purging. Although females with disordered eating may have amenorrhea, this adolescent shouldn't have a gynecologic examination unless a medical condition warrants one at a later time. She doesn't need a toxicology evaluation unless a severe substance-abuse problem is identified.

Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client?

Offer pain medication before having the client deep-breathe and use incentive spirometry. Explanation: Deep-breathing exercises and use of incentive spirometry are more effective when pain is minimal. A client in severe pain tends to limit movement and to breathe shallowly to decrease the pain. Enough pain medication should be given to decrease pain without depressing respirations. Administration of oxygen or forcing fluids will not prevent atelectasis or pneumonia. Deep-breathing exercises and use of incentive spirometry should be done 10 times every hour while awake. The client's position should be changed every 1 to 2 hours to allow for full chest expansion. Ambulation, not just sitting in the chair, should be implemented as soon as physician approval is obtained. (

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

Oxygen saturation (SaO2) of 89% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90% Explanation: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.

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?

Right lateral Correct Explanation: 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.

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment?

Speech therapist. Correct Explanation: The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of speech therapists. The physician should be made aware and respiratory therapy may be involved with assessing and promoting the client's oxygenation, but swallowing assessment is a task most often performed by a speech therapist

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Stop the feedings and check for residual volume. Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

Communicating with parents and children about health care has become increasingly significant because:

The influence of the media and specialization have increased the complexity of managing health. Explanation: Today's health care network includes many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring, to name a few. Due to expanded media coverage of health care issues, parents are more aware of health care issues but cannot understand all the ramifications of possible health care decisions. Because of this expanded media coverage, health care consumers are more aware of advances in the science of health care. Nurses have always recognized the value of communication and that all nurses are teachers. Clients are more aware of their rights through media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well and communicating with parents and children should not be impacted by a client's knowledge or demand for those rights

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

When assessing for oxygenation in a client with dark skin, the nurse should examine the client's:

The nurse should examine the buccal mucosa, along with the conjunctiva and sclera, nailbeds, palms, soles, lips, and tongue to assess for oxygenation in a client with dark skin.

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the accompanying chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?

The oxygen levels for this neonate have dropped during the last 8 hours; the nurse should administer oxygen, as the neonate is not obtaining adequate oxygenation on room air. The recommended pulse oximetry reading in a term neonate is 95% to 100%. Keeping the neonate warm may improve the oxygen saturation if that is the cause of the poor gas exchange, but overheating with warm blankets may increase oxygen demand. Waiting to reassess the neonate could cause the neonate to have inadequate oxygen levels unnecessarily. While blood gases may be drawn, the first action is to administer the oxygen.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias. Explanation: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.

The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.

Weigh weekly and report weight loss. • When eating, sit and lean slightly forward. • Have serum albumin level checked regularly. • Administer enteral tube feedings as ordered. Explanation: The nurse should monitor nutritional status through frequent weighing and checking the serum albumin level. The nurse also should administer enteral tube feedings until there is sufficient healing of pharynx, and the client can consume sufficient oral feedings to meet body needs. The nurse should avoid manipulation of the nasogastric tube during this time so it does not disrupt the suture line. The nurse should place the client in sitting position, leaning slightly forward, which allows the larynx to move forward and the hypopharynx to partially open; the epiglottis normally prevents fluid and food from entering the larynx during swallowing.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

ncreased restlessness Explanation: In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

The parents of an ill child are concerned because the child "isn't eating well." Which of the following strategies are appropriate approaches to encourage the child to eat. Select all that apply.

• Allowing the child to choose his meals from an acceptable list of foods. • Letting the child substitute items on his tray for other nutritious foods. • Asking the child to say why he is not eating. Explanation: Allowing children choices typically helps them feel in control. They also will be more likely to eat foods they have chosen. Letting the child substitute items on his tray for other nutritious foods is another way to allow the child to make choices, thus helping him to feel in control. It is important to find out why the child is not eating. Children refuse to eat for various reasons, and interventions should be devised that take into consideration the reason for the child's refusal. Although nutrition plays a large part in the healing process, it is not advisable to tell a child that he will not get better if he does or does not do a particular activity. Not only is this dishonest, it also makes the child believe that his own actions are causing the illness. Children usually eat better when their parents are present; there is no indication that the parents are contributing to the child's eating problem.

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths per minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply.

• Monitor serum creatinine and blood urea nitrogen levels. • Administer humidified oxygen. • Auscultate the lungs. Explanation: Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.

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.

• Pureed fruits • Rice cereal • Strained vegetables Explanation: 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 19-year-old G1 P0 is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which of the following? Select all that apply.

• Refer client to a nutritionist for the following day. • Ensure that the client has a prescription for an antiemetic. • Encourage return to normal routine when client feels ready. • Discuss plan of care and discharge instructions with client. Explanation: The nurse case manager should refer the client to a nutritionist so the client is aware of and can be monitored regarding her food intake to assure transition to a normal pregnancy diet with intake of adequate nutrients to support growth and development of the fetus. A prn (as needed) prescription for an antiemetic is useful to overcome occasional episodes of nausea and vomiting. Encouraging a return to normal activities when the client feels ready gives the client a goal to look forward to and activity is not contraindicated in hyperemesis when the client feels ready it initiate activity. Discussion of the plan of care and discharge instructions is a standard of care when discharging a client from a health care facility. There is no indication for an anxiolytic and hyperemesis gravidarum typically is not associated with anxiety. Six weeks is too long to wait for a follow-up appointment post hospitalization.

A nurse is caring for a client with emphysema. Which nursing interventions are appropriate? Select all that apply.

• Teach use of postural drainage and chest physiotherapy. • Encourage alternating activity with rest periods. • Teach diaphragmatic, pursed-lip breathing. • Administer low-flow oxygen. Correct Explanation: Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because the client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows the client to perform activities without excessive distress. If the client has copious secretions and has difficulty mobilizing secretions, the nurse should teach him and his family members how to perform postural drainage and chest physiotherapy. Fluid intake should be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client should be placed in high Fowler's position to improve ventilation.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.

• The SpO2 and PO2 have decreased. • The client is tachycardic with drop in blood pressure. • The face has increased skin breakdown and edema. Explanation: The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.