HESI MODULE
Lab results in FVD
elevated BUN in relation to serum creatinine, increased H&H, and possible serum electrolyte changes
Hyperkalemia S/S
• Muscle weakness• Bradycardia• Dysrhythmias• Flaccid paralysis• Intestinal colic• Tall T waves on ECG
S/S FVE
• Peripheral edema• Increased bounding pulse• Elevated BP• Distended neck and hand veins• Dyspnea; moist crackles heard when lungs auscultated• Attention loss, confusion, aphasia• Altered level of consciousness
Tx in FVD
• Strict I&O• Replacement of fluids isotonically, preferably orally• Water is a hypotonic fluid.• If intravenous hydration is needed, isotonic fluids are used.
S/S FVD
• Weight loss (1 liter of fluid weight loss or gain is approximately equal to 2.2 pounds or 1 kilogram)• Decreased skin turgor• Oliguria (concentrated urine)• Dry and sticky mucous membranes• Postural hypotension or weak, rapid pulse
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A. Trichomoniasis B. Chlamydia C. Staphylococcus D. Streptococcus
•Answer: B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
respiratory acidosis
A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.
A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have?
A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae
A 28-year-old male has been found wandering around in a confused pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first? A. Blood sugar check B. CT scan C. Blood cultures D. Arterial blood gases
Answer: A. Blood sugar check With a history of diabetes, the first response should be to check blood sugar levels.
A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?" A. Green vegetables and liver B. Yellow vegetables and red meat C. Carrots D. Milk
Answer: A. Green vegetables and liver Green vegetables and liver are a great source of folic acid.
Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urineglucose testing because... A. More accurate B. Can be done by the client C. It is easy to perform D. It is not influenced by drugs
Answer: A. More accurate •Option A: Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
Jerry has diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications? A. Intestinal obstruction B. Peritonitis C. Bowel ischemia D. Deficient fluid volume
Answer: B. Peritonitis •Option B: Complications of acute appendicitis are peritonitis, perforation and abscess development.
A patient's chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute? A. Decreased HR B. Paresthesias C. Muscle weakness of the extremities D. Migraines
Answer: D. Migraines Answer choices A-C were symptoms of acute hyperkalemia.•
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to: A. Achieve harmony B. Maintain a balance of energy C. Respect life D. Restore yin and yang
Answer: D: Restore yin and yang For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang.
List three categories of medications used in the treatment of PUD.
Antacids, H2 receptor blockers, mucosal healing agents, proton pump inhibitors
What is the rationale for using the nursing process in planning care for clients? As a scientific process to identify nursing diagnoses of a clients' healthcare problems. To establish nursing theory that incorporates the biopsychosocial nature of humans. As a tool to organize thinking and clinical decision making about clients' healthcare needs. To promote the management of client care in collaboration with other healthcare professionals.
As a tool to organize thinking and clinical decision making about clients' healthcare needs.
In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List six relevant nursing interventions.
Avoid injections; use small-bore needles for IV insertion; maintain pressure for 5 minutes on all venipuncture sites; use electric razor; use soft-bristle toothbrush for mouth care; check stools and emesis for occult blood.
Hyperkalemia Tx
Eliminate parenteral K+ from IV inf and meds; Admin 50% glucose with regular insulin; Admin Kayexalate; Monitor ECG, Admin calcium gluconate to protect the heart; IV loop diuretics may be prescribed; Renal dialysis may be required
Hypercalcemia Tx
Eliminate parenteral calcium; Admin agents to reduce calcium levels (calcitonin); Avoid calcium-based antacids; Renal dialysis may be required
What are the common side effects of salicylates?
GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation.
How should the nurse administer pancreatic enzymes?
Give with meals or snacks. Powder forms should be mixed with fruit juices.
Name three food sources of vitamin B12.
Glandular meats (liver), milk, green leafy vegetables
Which age-related effects on the immune system are seen in the older client? Increased autoantibodies Increased expression of IL-2 receptors Increased delayed hypersensitivity reaction Increased primary and secondary antibody responses
Increased autoantibodies Increased expression of IL-2 receptors Increased delayed hypersensitivity reaction
When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? Locate the perineum. Transfer to a commode. Attach the catheter to a drainage bag. Manipulate a syringe to inflate the balloon.
Locate the perineum.
Identify two sites that should be assessed for infection in immunosuppressed clients.
Oral cavity and genital area
When preparing a client with diabetes for discharge, the nurse teaches the client the relationship between stress, exercise, bedtime snacking, and glucose balance. State the relationships among each of these.
Stress and stress hormones usually increase glucose production and increase insulin need. Conversely, exercise may increase the chance of a hypoglycemic reaction; therefore the client should always carry a fast-acting source of carbohydrate, such as glucose tablets or hard candies, when exercising.
What diagnostic test is used to determine thyroid activity?
T3, T4
Which act protects a person who is HIV positive? The National Organ Transplant Act The Americans with Disabilities Act (ADA) The Patient Self-Determination Act (PSDA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Americans with Disabilities Act (ADA)
Hypocalcemia causes
• Renal failure• Hypoparathyroidism• Malabsorption• Pancreatitis• Alkalosis
Differentiate between acute renal failure and chronic renal failure.
Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis is required.
A nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern? A. Bowel perforation. B. Viral Gastroenteritis. C. Colon cancer D. Diverticulitis.
Answer: A. Bowel perforation Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate advancing peritonitis. Options B and C: Viral gastroenteritis and colon cancer do not cause these symptoms. Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis.
After gastroscopy, an adaptation that indicates major complication would be: A. Nausea and vomiting B. Abdominal distention C. Increased GI motility D. Difficulty in swallowing
Answer: B. Abdominal distention Option B: Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
A 65-year-old man has been admitted to the hospital for spinal stenosis surgery. When should the discharge training and planning begin for this patient? A. Following surgery B. Upon admit C. Within 48 hours of discharge D. Preoperative discussion
Answer: B. Upon admit Discharge education begins upon admission.
Which of the following conditions would a nurse not administer erythromycin? A. Campylobacteriosis infection B. Legionnaire's disease C. Pneumonia D. Multiple Sclerosis
Answer: D. Multiple Sclerosis Erythromycin is used to treat conditions A-C.
Main function of the kidneys is to filter a person's blood and adjust the amount and composition of fluids in the body. The total blood volume is determined by a client's gender, height, and weight. The average healthy adult has approximately 5.2 to 6 liters of circulating blood in the body.
As a result of this filtration process, the kidney selectively maintains and excretes body fluids, producing approximately 1 to 2 liters of urine.
FYI: BUN
Elevated BUN: The BUN measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys.
A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? Generativity. Ego integrity. Identification. Valuing wisdom.
Generativity.
When making rounds at night, the nurse notes that a client prescribed insulin is complaining of a headache, slight nausea, and minimal trembling. The client's hand is cool and moist. What is the client most likely experiencing?
Hypoglycemia/insulin reaction
What condition results from all treatments for hyperthyroidism?
Hypothyroidism, requiring thyroid replacement
When caring for an immobile client, what nursing diagnosis has the highest priority? Risk for fluid volume deficit. Impaired gas exchange. Risk for impaired skin integrity. Altered tissue perfusion.
Impaired gas exchange.
Which statement is an example of a correctly written nursing diagnosis statement? Altered tissue perfusion related to congestive heart failure. Altered urinary elimination related to urinary tract infection. Risk for impaired tissue integrity related to client's refusal to turn. Ineffective coping related to response to positive biopsy test results.
Ineffective coping related to response to positive biopsy test results
The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) Pre-medicate the client with an analgesic. Inform the client of the plan for moving to the chair. Obtain and place a portable commode by the bed. Ask the client to push the IV pole to the chair. Clamp the indwelling catheter. Assess the client's blood pressure.
Inform the client of the plan for moving to the chair. Assess the client's blood pressure.
A nurse teaches about osteochondroma. Which information should the nurse include in the teaching session? It is a common malignant tumor. It occurs most often in the age group of 10 to 25. It has a high rate of local occurrence after surgery. It frequently arises in cancellous ends of arm and leg bones.
It occurs most often in the age group of 10 to 25. Rationale Osteochondroma is common in the age group of 10 to 25 years. It is a primary benign tumor. Osteoclastoma has a high rate of local occurrence after surgery and chemotherapy. Osteoclastoma frequently arises in cancellous ends of arm and leg bones; osteocondroma occurs in the metaphyseal portion of long bones.
Lungs in acid/base balance
Lungs control the supply of carbonic acid (CO2, H20) -amount altered by depth and rate of breathing Rid the body of approximately 300 to 500 mL of fluid daily through the process of inhalation and exhalation. Hypoventilation = retention of acid Hyperventilation = loss of acid
List three systems that maintain acid-base balance.
Lungs; kidneys; chemical buffers
After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? Notify the surgeon that the consent form has not been signed. Read the consent form to the client before witnessing the client's signature. Determine if the client's spouse is willing to sign the consent form. Administer an opioid antagonist prior to obtaining the client's signature.
Notify the surgeon that the consent form has not been signed.
A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do? Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. Nurse Practice Acts reflect the knowledge and skills possessed by nurses practicing in their profession. Nurse Practice Acts are legal requirements that describe the minimum acceptable nursing care. Nurse Practice Acts protect individuals from losing their health insurance when changing jobs by providing portability.
Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state.
Fluid Volume Excess
Occurs when the body retains water and electrolytes isotonically• Water intoxication: state in which the body retains water and serum sodium levels decrease
Which hormone promotes bone resorption in a client? Estrogen Calcitonin Growth hormone Parathyroid hormone (PTH)
Parathyroid hormone (PTH) Rationale When serum calcium levels are lowered, secretion of PTH increases and stimulates bones to promote osteoclastic activity, which promotes bone resorption. Estrogens stimulate osteoblastic (bone-building) activity and inhibit PTH. Calcitonin inhibits bone resorption and increases the renal excretion of calcium and phosphorus as needed to maintain balance in the body. Growth hormones secreted by the anterior lobe of the pituitary gland are responsible for increasing bone length.
A client in labor is having an indwelling urinary catheter inserted. What should the nurse plan to do to prevent late decelerations of the fetal heart rate during this procedure? Position both the client's legs simultaneously. Urge the client to take deep breaths frequently. Place a rolled towel under the client's right hip. Loosen the transducer belts around the client's abdomen.
Place a rolled towel under the client's right hip. Rationale Elevating the right hip during catheter insertion displaces the uterus to the left. This action improves placental perfusion and prevents supine hypotension caused by pressure on the vena cava with its associated late fetal heart rate decelerations. Placing the feet in stirrups simultaneously helps prevent trauma to ligaments at the time of birth; it is not done when a urinary catheter is inserted. Breathing frequently is contraindicated because hyperventilation may result. Adjusting the belts around the client's abdomen does not affect the fetal heart rate.
Hypophosphatemia causes
Refeeding after starvation Alcohol withdrawal Diabetic ketoacidosis Respiratory alkalosis
After kidney surgery, what are the primary assessments the nurse should make?
Respiratory status (breathing is guarded because of pain); circulatory status (the kidney is very vascular and excessive bleeding can occur); pain assessment; urinary assessment (most important, assessment of urinary output).
While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? Lung biopsy Thoracentesis Mediastinoscopy Ventilation-perfusion scan
Thoracentesis Rationale A thoracentesis is performed to obtain a specimen of pleural fluid for diagnosis. The client should be positioned upright with elbows on an overbed table with the feet supported. The client should not talk or cough during the procedure because the inserted needle may cause trauma. A lung biopsy or mediastinoscopy may not require the client to be seated upright. No special precautions are needed after performing ventilation-perfusion scan because the gas and isotope transmits radioactivity for only a brief interval.
According to Quality and Safety Education (QSEN), what is patient-centered care? Understanding that the client is the source of control when providing care Functioning effectively within nursing and interprofessional teams to deliver quality care Using data to evaluate outcomes of care processes and designing methods to improve health care Minimizing the risk of harm to clients and health care workers through improved professional performance
Understanding that the client is the source of control when providing care Rationale The Quality and Safety Education (QSEN) competency called patient-centered care requires the nurse to understand that the client is the source of control. The nurse should therefore respect the values, beliefs, and preferences of the client to provide quality care. The QSEN competency called teamwork and collaboration states that a nurse should function effectively within nursing and interprofessional teams in order to provide quality care. Quality improvement involves using data to evaluate the outcomes of care processes and design methods to improve the health care delivery system. Safety focuses on minimizing the risk of harm to clients and health care workers through improved professional performance.
A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause? Warfarin Nifedipine Nitrofurantoin Phenazopyridine
Warfarin Rationale Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.
What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis?
Diarrhea
A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child? Flexion of the hip Extension of the hip Adduction of the hip Abduction of the hip
Abduction of the hip Rationale Abduction will enable the head of the femur to fit into the acetabulum, thereby correcting the dysplasia. Flexion causes the head of the femur to move away from the acetabulum. Extension causes the head of the femur to move away from the acetabulum. Adduction causes the head of the femur to move away from the acetabulum.
Hypocalcemia Tx
Admin calcium supplements PO 30m before meals; Admin calcium IV slowly (infiltration can cause tissue necrosis); Increase calcium intake
Hypomagnesemia Tx
Admin magnesium sulfate IV; Enc foods high in Mg+ (e.g., meats, nuts, legumes, fish, and vegetables).
What is the priority nursing intervention used with clients taking NSAIDs?
Administer or teach client to take drugs with food or milk.
A client in renal failure asks why antacids are being given. How should the nurse reply?
Calcium and aluminum antacids bind phosphates and help keep phosphates from being absorbed into bloodstream, thereby preventing rising phosphate levels; must be taken with meals.
The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? Portable syringe pump. Cassette infusion pump. Volumetric controller. Nonvolumetric controller.
Cassette infusion pump.
Identify five foot-care interventions that should be taught to a client with diabetes.
Check feet daily, and report any breaks, sores, or blisters to health care provider; wear well-fitting shoes; never go barefoot or wear sandals; never personally remove corns or calluses; cut or file nails straight across; wash feet daily with mild soap and warm water.
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? Check for a pulse Start cardiac compressions Prepare to defibrillate the client Administer oxygen via an ambu bag
Check for a pulse Rationale The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.
The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? Complains of inability to empty bladder. Temperature of 99.8 ??F and pulse of 108. Post-voided residual volume of 750 ml. Specimen collection for culture and sensitivity.
Complains of inability to empty bladder.
What action should the nurse implement when adding sterile liquids to a sterile field? Use an outdated sterile liquid if the bottle is sealed and has not been opened. Consider the sterile field contaminated if it becomes wet during the procedure. Remove the container cap and lay it with the inside facing down on the sterile field. Hold the container high and pour the solution into a receptacle at the back of the sterile field.
Consider the sterile field contaminated if it becomes wet during the procedure.
Hypocalcemia S/S
Diarrhea, Numbness, Tingling of extremities and around mouth, Convulsions, Positive Chvostek sign, Positive Trousseau sign, *Pt at risk for tetany.
List three potential causes of anemia.
Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents such as lead or insecticides.
Which method of drug administration does the nurse state is commonly used in toddlers when the child has poor intravenous (IV) access? Intrathecal Intraarterial Intraosseous Intraperitoneal
Intraosseous Rationale The intraosseous route is commonly used in toddlers for drug administration in an emergency situation. It is most commonly used in infants and toddlers in whom there is poor access to the intravascular space. Intrathecal administration is often associated with long-term medication administration through surgically implanted catheters. Intraarterial infusions are common in clients who have arterial clots. Chemotherapeutic agents, insulin, and antibiotics are administered via the intraperitoneal route.
List four nursing interventions for postoperative care of a client with a colostomy.
Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least ⅛ inch around the stoma.
How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? It is a willful act violating a client's rights. It is a civil wrong made against a person or property. It is an act that lacks intent but involves volitional action. It is an unintentional act that includes negligence and malpractice.
It is an act that lacks intent but involves volitional action. Rationale A quasi-intentional tort lacks intent but involves volitional actions such as invasion of privacy and defamation of character. An intentional tort is a willful act that violates another's rights. This includes assault, battery, and false imprisonment. A tort is a civil wrong made against a person or property. An unintentional tort involves negligence and malpractice.
Which nursing theory focuses on the client's self-care needs? Roy's theory Orem's theory Watson's theory Leininger's theory
Orem's Rationale Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.
Hypophosphatemia S/S
Paresthesias, Muscle weakness, Muscle pain, Mental changes, Cardiomyopathy, Respiratory failure
List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.
Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return
In which part of the client's body is the amphiarthroidial joint located? Pelvis Elbow Cranium Shoulder
Pelvis Rationale Amphiarthrodial joints are slightly movable joints located in the pelvis. The elbow joint is freely movable; it is referred to as a diarthrodial joint. The joint at the cranium is an immovable synarthrodial joint. The shoulder joint is movable (ball and socket) and is referred to as a diarthrodial joint.
What is an important nursing intervention in the care of a hospitalized toddler with cystic fibrosis? Discouraging coughing Performing postural drainage Encouraging active exercise Providing small, frequent feedings
Performing postural drainage Rationale Because the mucus glands secrete thick mucoid secretions that accumulate, reducing ciliary action and mucus flow, the nurse should perform postural drainage, which promotes the removal of mucopurulent secretions by means of gravity. Coughing should be encouraged; it helps bring up secretions from the respiratory tract. Although the nurse should encourage activities that are appropriate for the child's physical capacity, the child's energy should be conserved during acute phases of illness. Providing small, frequent feedings is not necessary; the child with cystic fibrosis may eat regular meals at the usual times.
Differentiate between rheumatoid arthritis and OA in terms of joint involvement.
Rheumatoid arthritis occurs bilaterally. OA occurs asymmetrically.
What is the highest priority nursing diagnosis for clients in any type of renal failure?
Risk for imbalanced fluid volume
List the common clinical manifestations of jaundice.
Scleral icterus (yellow sclera), dark urine, chalky or clay-colored stools
pituitary gland and acid/base balance
Secretes antidiuretic hormone (ADH), which causes the body to retain water by signaling the kidneys to increase the water absorption when filtering the blood.
Name the necessary elements to include in teaching a client newly diagnosed with diabetes.
The underlying pathophysiology of the disease; its management and treatment regimen; meal planning; exercise program; insulin administration; sick-day management; symptoms of hyperglycemia (not enough insulin); symptoms of hypoglycemia (too much insulin, too much exercise, not enough food); foot care
Hyperphosphatemia causes
Renal failure Excess intake of phosphorus
Hypermagnesemia causes
Renal failure, Adrenal insufficiency, Excess replacement
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis Rationale The pH indicates acidosis[1][2]; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.
What are the most important nursing interventions for clients with possible renal calculi?
Straining all urine is the most important intervention. Other interventions include accurate I&O documentation and administering analgesics as needed.
What nursing intervention does a nurse provide during the initiative versus guilt stage? Teaching parents about child impulse control Helping the client decide his or her treatment plan Guiding parents to help their child achieve self-control Assisting individuals in choosing ways to foster social development
Teaching parents about child impulse control Rationale The initiative versus guilt stage is seen in children between ages three to six years. During this stage, the nurse should teach parents about child impulse control and cooperative behaviors for better growth and development of the child. During the identity versus role of confusion stage, the nurse should provide enough information to the adolescents, which allow them to choose the treatment plan. The nurse guides the parents to help their child achieve self-control and willpower during the stage of autonomy versus shame and doubt. The nurse assists ill adults in choosing creative ways to foster their social development during the generativity versus self-absorption and stagnation stage.
Which treatment is beneficial for a client with muscle spasm? Thermotherapy Muscle massage Frequent position changes Muscle-strengthening exercise regimen
Thermotherapy Rationale Thermotherapy, the use of heat therapy, eases pain and muscle contraction; therefore it is useful in treating muscle spasms. Muscle massage stimulates muscle tissue contraction and may worsen a muscle spasm. Frequent position changes are beneficial for a client with contracture. A muscle-strengthening exercise regimen is beneficial for a client with muscle atrophy.
A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise? To decrease insulin sensitivity To stimulate glucagon production To improve the cellular uptake of glucose To reduce metabolic requirements for glucose
To improve the cellular uptake of glucose Rationale Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.
During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction?
Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein catabolism.
Identify two examples of isotonic IV fluids.
a. Ringers lactate b. Normal saline
metabolic acidosis
decreased pH in blood and body tissues as a result of an upset in metabolism
Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. Interventions to restore tissue integrity Interventions to optimize neurologic functions Interventions to manage restricted body movements Interventions to promote comfort using psychosocial techniques Interventions to provide care before, during, and immedi
nterventions to restore tissue integrity Interventions to optimize neurologic functions Interventions to provide care before, during, and immediately after surgery
Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of: A. Osmosis B. Diffusion C. Active transport D. Filtration
Answer: A. Osmosis Option A:Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A. Verify correct placement of the tube B. Check that the feeding solution matches the dietary order C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D. Ensure that feeding solution is at room temperature
Answer: A: Verify correct placement of the tube Proper placement of the tube prevents aspiration.
A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission? A. Sexual contact with an infected partner. B. Contaminated food. C. Blood transfusion. D. Illegal drug use.
Answer: B. Contaminated food. Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food.
Which of the following conditions most commonly causes acute glomerulonephritis? A. A congenital condition leading to renal dysfunction. B. Prior infection with group A Streptococcus within the past 10-14 days. C. Viral infection of the glomeruli. D. Nephrotic syndrome.
Answer: B. Prior infection with group A Streptococcus within the past 10-14 days. Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? A. Electrical energy fields B. Spinal column manipulation C. Mind-body balance D. Exercise of joints
Answer: B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to: A. Turning the client to the left side B. Milking the tube to ensure patency C. Slowing the intravenous infusion D. Notifying the physician
Answer: D. Notifying the physician•The output of 300 mL is indicative of hemorrhage and should be reported immediately. •Option A: Turning the client to the left side does nothing to help the client. •Options B and C: Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not an appropriate action.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? Take the child back to his room. Recruit others to restrain the child. Ask the mother to be present to soothe the child. Show the child how to manipulate the equipment.
Ask the mother to be present to soothe the child.
metabolic alkalosis
elevation of HCO3- usually caused by an excessive loss of metabolic acids
A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes? "A nurse should provide a personal point of view." "Negotiations should be held in formal settings only." "Negotiation takes place immediately after gathering information." "The group agrees to a statement of the problem during the negotiation process."
"A nurse should provide a personal point of view." Rationale During the process of negotiating outcomes, the nurse is required to provide a personal point of view. Negotiations may take place informally at the client's bedside or in a formal setting. After gathering relevant information regarding an ethical dilemma, the nurse is required to examine his or her own values and formulate an opinion regarding the matter. When verbalizing the problem, the group agrees to a statement of the problem to begin discussions. This step is performed before negotiating outcomes. Negotiations take place after determining all possible courses of action.
A registered nurse is teaching a nursing student about the components of the magnet model. What information should the registered nurse provide about exemplary professional practice according to the revised magnet model? "Strong professional practice is established, and accomplishments of the practice are demonstrated." "A vision for the future and the systems and resources to achieve the vision are created by nursing leaders." "Focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes." "Structures and processes provide an innovative environment in which staff are developed and empowered and professional practice flourishes."
"Strong professional practice is established, and accomplishments of the practice are demonstrated." Rationale Exemplary professional practice is evident when a strong professional practice is established, and accomplishments of the practice are demonstrated. The characteristic of transformational leadership is a vision for the future and the systems and resources to achieve the vision are created by nursing leaders. The characteristic of empirical quality outcomes is that the focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes. The characteristic of structural empowerment includes structures and processes to provide an innovative environment in which staff are developed and empowered and professional practice flourishes.
A registered nurse is educating a nursing student about the stages of changes in a client's health behavior. Which statement describes the stage of contemplation? "The client considers a change within the next 6 months." "The client does not intend to make changes within the next 6 months." "The client is actively engaged in strategies to change behavior; this lasts up to 6 months." "The client displays sustained change over time; this begins 6 months after action has started and continues indefinitely."
"The client considers a change within the next 6 months." Rationale In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time and begins 6 months after action has started and continues indefinitely, the client has reached the maintenance stage.
A registered nurse is teaching a nursing student about Maslow's hierarchy of needs. Which statement made by the nursing student needs correction? "The hierarchy of basic human needs includes five levels of priority." "The second level includes safety and security needs, which involve physical and psychological security." "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life."
"The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." Rationale The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization.
A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? Telling the other clients to disregard what the client is saying Ignoring the client's disruptive behavior and waiting for it to subside Restricting the client's contact with other clients until the disruptive behavior ceases Accepting that the client is unable to control this behavior and setting appropriate limits
Accepting that the client is unable to control this behavior and setting appropriate limits Rationale Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.
Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? Provide some dry crackers to eat Administer the prescribed antiemetic Explain that this is expected after surgery Encourage deep breathing until the nausea subsides
Administer the prescribed antiemetic
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case? Assess the amount and color of urine; obtain a specimen for a urinalysis. Administer the prescribed antipyretic and notify the primary health care provider. Note the consistency of respiratory secretions and obtain a specimen for culture. Obtain the respirations, pulse, and blood pressure; recheck the temperature in 1 hour.
Administer the prescribed antipyretic and notify the primary health care provider. Rationale Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia then can be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure is rechecking the temperature in 1 hour. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also, the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? A. A tracheotomy set B. A padded tongue blade C. An endotracheal tube D. An airway
Answer: A. A tracheotomy set •The client who has recently had a thyroidectomy is at risk for tracheal edema. •Option B: padded tongue blade is used for seizures and not for the client with tracheal edema. •Options C and D: If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem
Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom? A. Absence of drainage from the ileostomy for 6 or more hours B. Passage of liquid stool in the stoma C. Occasional presence of undigested food D. A temperature of 37.6 °C
Answer: A. Absence of drainage from the ileostomy for 6 or more hours Option A: Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed.
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is: A. Blood pressure B. Temperature C. Output D. Specific gravity
Answer: A. Blood pressure Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, •Options B, C, and D: Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders.
A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient's lab results would expect which of the following changes in laboratory findings? A. Elevated serum calcium B. Low serum parathyroid hormone (PTH). C. Elevated serum vitamin D. D. Low urine calcium.
Answer: A. Elevated serum calcium. The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. Option B: Parathyroid hormone levels may be high or normal but not low. Option C: The body will lower the level of vitamin D in an attempt to lower calcium. Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones.
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to: A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation
Answer: A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2-8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2-3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. Options B, C, and D: There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair.
A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? A. Glucometer readings as ordered B. Intake/output measurements C. Sodium and potassium levels monitored D. Daily weights
Answer: A. Glucometer readings as ordered IV glucocorticoids raise the glucose levels and often require coverage with insulin. •Options B, C, and D: Intake/output measurements is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineralocorticoids, and daily weights is unnecessary.
A client is discharged home with a prescription for Coumadin (sodiumwarfarin). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds
Answer: A. Have a Protime done monthly Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. •Option B: Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting. •Options C and D: Drinking more liquids and avoiding crowds is not necessary.
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the: A. Head of the pancreas B. Proximal third section of the small intestines C. Stomach and duodenum D. Esophagus and jejunum
Answer: A. Head of the pancreas During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and anastomosed.
A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient? A. Naproxen sodium (Naprosyn). B. Calcium carbonate. C. Clarithromycin (Biaxin). D. Furosemide (Lasix).
Answer: A. Naproxensodium (Naprosyn). Naproxensodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis.
Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem? A. Regular insulin B. Potassium C. Sodium bicarbonate D. Calcium gluconate
Answer: A. Regular insulin •Option A: Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock? A. Systolic blood pressure less than 90mm Hg B. Pupils unequally dilated C. Respiratory rate of 4 breath/min D. Pulse rate less than 60 bpm
Answer: A. Systolic blood pressure less than 90mm Hg •Option A: Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with Cushing's disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema
Answer: A. The client with Cushing's disease•The client with Cushing's disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. Option B: the client with diabetes poses no risk to other clients. Option C: The client has an increase in growth hormone and poses no risk to himself or others. Option D: The client has hypothyroidism or myxedema and poses no risk to others or himself.
A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A. Blood pressure 94/60 B. Heart rate 76 C. Urine output 50 ml/hour D. Respiratory rate 16
Answer: A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications.
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A. Should be taken in the morning B. May decrease the client's energy level C. Must be stored in a dark container D. Will decrease the client's heart rate
Answer: A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states "My blood pressure is usually much lower." The nurse should tell the client to A. go get a blood pressure check within the next 48 to 72 hours B. check blood pressure again in two (2) months C. see the healthcare provider immediately D. visit the health care provider within one (1) week for a BP check
Answer: A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is 'usually much lower.' Thus a concern exists for complications such as stroke. However, immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg
Answer: B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg HR and Respirations are slightly increased. BP is down.
A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started? A. The admission orders are written. B. A blood culture is drawn. C. A complete blood count with differential is drawn. D. The parents arrive.
Answer: B. A blood culture is drawn.•Antibiotics must be started after the blood culture is drawn, as they may interfere with the identification of the causative organism. Option C: The blood count will reveal the presence of infection but does not help identify an organism or guide antibiotic treatment. Option D: Parental presence is important for the adjustment of the child but not for the administration of medication.
The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to: A. Administer the medications together in one syringe B. Administer the medication separately C. Administer the Valium, wait 5 minutes, and then inject the Phenergan D. Question the order because they cannot be given at the same time
Answer: B. Administer the medication separately Option A: Valium is not given in the same syringe with other medications. Option C: it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic. Option D: These medications can be given to the same client.
Which of the following potentially serious complications could occur with therapy for hypothyroidism? A. Acute hemolytic reaction. B. Angina or cardiac arrhythmia. C. Retinopathy. D. Thrombocytopenia.
Answer: B. Angina or cardiac arrhythmia. Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. Option A: Acute hemolytic reaction is a complication of blood transfusions. •Option C: Retinopathy typically is a complication of diabetes mellitus. •Option D: Thrombocytopenia doesn't result from treating hypothyroidism.
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse's next action be? A. Obtain a crash cart B. Check the calcium level C. Assess the dressing for drainage D. Assess the blood pressure for hypertension
Answer: B. Check the calcium level The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. •Option A: The crash cart would be needed in respiratory distress but would not be the next action to take. •Options C and D: Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage.
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: A. Measure the urinary output B. Check the vital signs C. Encourage increased fluid intake D. Weigh the client
Answer: B. Check the vital signs•A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria. Option C: Encouraging fluid intake will not correct the problem. Option D: Weighing the client is not necessary at this time.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority? A. Continuing to monitor the vital signs B. Contacting the physician C. Asking the client how he feels D. Asking the LPN to continue the post-op care
Answer: B. Contacting the physician•The vital signs are abnormal and should be reported immediately. Option A: Continuing to monitor the vital signs can result in deterioration of the client's condition. Option C: Asking the client how he feels will only provide subjective data. Option D: Assigning an unstable client to an LPN is inappropriate.
Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? A. Nutrition management. B. Fluid and electrolyte balance. C. Management of hypoglycemia. D. Pain control.
Answer: B. Fluid and electrolyte balance. •Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and restore electrolyte balance. •Options A & D: Pain control and nutrition also are important, but not priority. •Option C: Patients are at risk for hyperglycemia, not hypoglycemia.
A 24-year-old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect? A. Diverticulosis B. Hypercalcemia C. Hypocalcemia D. Irritable bowel syndrome
Answer: B. Hypercalcemia Hypercalcemia can cause polyuria, severe abdominal pain, and confusion. Option A: Diverticulosis is a condition that develops when pouches (diverticula) form in the wall of the large intestine; most people don't have symptoms. Option C:Hypocalcemia is low calcium levels in the blood; it is asymptomatic in mild forms but can cause paresthesia, tetany, muscle cramps, and carpopedal spasms in severe hypocalcemia. Option D: Irritable bowel syndrome is a widespread condition involving recurrent abdominal pain and diarrhea or constipation, often associated with stress, depression, anxiety, or previous intestinal infection
A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is: A. Start a peripheral IV B. Initiate high-quality chest compressions C. Establish an airway D. Obtain the crash cart
Answer: B. Initiate high-quality chest compressions As per new guidelines, the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults, children, and infants needing CPR, but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication? A. Treatment is not recommended for children less than 10 years of age. B. The entire family should be treated. C. Medication therapy will continue for 1 year. D. Intravenous antibiotic therapy will be ordered.
Answer: B. The entire family should be treated. Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth(pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain.
A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient? A. The patient is allergic to shellfish. B. The patient has a pacemaker. C. The patient suffers from claustrophobia. D. The patient takes anti-psychotic medication.
Answer: B. The patient has a pacemaker.•The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Option A: Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. Options C and D: Open MRI scanners and anti-anxiety medications are available for patients with claustrophobia. Psychiatric medication is not a contraindication to MRI scanning.
The nurse is caring for a client who had a total hip replacement four (4) days ago. Which assessment requires the nurse's immediate attention? A. I have bad muscle spasms in my lower leg of the affected extremity. B. "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C. "I have to use the bedpan to pass my water at least every 1 to 2 hours." D. "It seems that the pain medication is not working as well today."
Answer: B: "I just can't "catch my breath" over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However, the most life-threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life-threatening.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A. Increase the heart rate B. Lead to dehydration C. Are considered aerobic D. May be competitive
Answer: B: Lead to dehydration The client must take in adequate fluids before and during exercise periods.
A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy
Answer: C. Autonomic neuropathy Autonomic neuropathy (also known as Diabetic Autonomic Neuropathy) affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs. Paralysis of the bladder is a common symptom of this type of neuropathy.
A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first? A. Blood sugar check B. CT scan C. Blood cultures D. Arterial blood gases
Answer: C. Blood cultures Blood cultures would be performed to investigate the fever and rash symptoms
A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? A. Place the client in Trendelenburg position for postural drainage B. Encourage coughing and deep breathing every 2 hours C. Elevate the head of the bed 30° D. Encourage the Valsalva maneuver for bowel movements
Answer: C. Elevate the head of the bed 30°•Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Options A, B, and D:Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
A 25-year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal? A. Bradycardia B. Decreased appetite C. Exophthalmos D. Weight gain
Answer: C. Exophthalmos•Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. •Options A, B, and D: The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.
Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site? A. Thoroughly irrigate the wound before collecting the specimen. B. Use a sterile swab and wipe the crusty area around the outside of the wound. C. Gently roll a sterile swab from the center of the wound outward to collect drainage. D. Use a sterile swab to collect drainage from the dressing.
Answer: C. Gently roll a sterile swab from the center of the wound outward to collect drainage. •Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound. •Option A: Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting microorganisms. •Option B: The outside of the wound and the dressing may be colonized with microorganisms that haven't affected the wound, so specimens from these sites could give inaccurate results.
A patient with a history of diabetes mellitus is on the second post-operative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms? A. Anesthesia reaction. B. Hyperglycemia. C. Hypoglycemia. D. Diabetic ketoacidosis.
Answer: C. Hypoglycemia. A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. Option A: An anesthesia reaction would not occur on the second postoperative day. Options B and D: Hyperglycemia and ketoacidosis do not cause confusion and shakiness.
Corticosteroids are potent suppressors of the body's inflammatory response. Which of the following conditions or actions do they suppress? A. Cushing syndrome. B. Pain receptors. C. Immune response. D. Neural transmission.
Answer: C. Immune response. •Corticosteroids suppress eosinophils, lymphocytes, and natural-killer cells, inhibiting the natural inflammatory process in an infected or injured part of the body. This helps resolve inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and depresses phagocytosis of tissues by white blood cells, thus blocking the release of more inflammatory materials. Excessive corticosteroid therapy can lead to Cushing's syndrome.
Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? A. No changes. B. Less insulin. C. More insulin. D. Oral diabetic agents.
Answer: C. More insulin. •During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels.
A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate? A. The child has a poor chance of recovery without joint deformity. B. Most children progress to adult rheumatoid arthritis. C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. D. Physical activity should be minimized.
Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized. Options A and B: Half of children with the disorder recover without joint deformity and about a third will continue with symptoms into adulthood. Option D: Physical activity is an integral part of therapy.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: A. Body image disturbance B. Impaired verbal communication C. Risk for aspiration D. Pain
Answer: C. Risk for aspiration•Always remember your ABCs (airway, breathing, circulation) when selecting an answer. •Option A: does not apply for a child who has undergone a tonsillectomy. •Options B and D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority.
A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage? A. The tumor is less than 3 cm. in size and requires no chemotherapy. B. The tumor did not extend beyond the kidney and was completely resected. C. The tumor extended beyond the kidney but was completely resected. D. The tumor has spread into the abdominal cavity and cannot be resected.
Answer: C. The tumor extended beyond the kidney but was completely resected. The staging of Wilm's tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
An 84-year-old male has been losing mobility and gaining weight over the last two (2) months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed? A. FBC (full blood count) B. ECG (electrocardiogram) C. Thyroid function tests D. CT scan
Answer: C. Thyroid function tests Weight gain and poor temperature tolerance indicate something may be wrong with the thyroid function.
A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that: A. "Most people need to eat a high protein diet for 12 months after surgery" B. "I should not eat those foods that upset me before the surgery" C. "I should avoid fatty foods as long as I live" D. "Most people can tolerate regular diet after this type of surgery"
Answer: D. "Most people can tolerate regular diet after this type of surgery" Option D: It may take 4 to 6 months to eat anything, but most people can eat anything they want.
A patient with Addison's disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is NOT recommended? A. A diet high in grains. B. A diet with adequate caloric intake. C. A high protein diet. D. A restricted sodium diet.
Answer: D. A restricted sodium diet. A patient with Addison's disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates, including grains.
The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? A. Ham sandwich on whole-wheat toast B. Spaghetti and meatballs C. Hamburger with ketchup D. Cheese omelet
Answer: D. Cheese omelet The child with celiac disease should be on a gluten-free diet.
Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? A. Bile green B. Bright red C. Cloudy white D. Dark brown
Answer: D. Dark brown Option D: 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? A. Impaired physical mobility related to decreased endurance B. Hypothermia r/t decreased metabolic rate C. Disturbed thought processes r/t interstitial edema D. Decreased cardiac output r/t bradycardia
Answer: D. Decreased cardiac output r/t bradycardia The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices.
A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? A. IgA B. IgD C. IgE D. IgG
Answer: D. IgG IgG is the only immunoglobulin that can cross the placental barrier. Option A: IgA antibodies protect body surfaces that are exposed to outside foreign substances. Option B: IgD antibodies are found in small amounts in the tissues that line the belly or chest. Option C: IgE antibodies cause the body to react against foreign substances such as pollen, spores, animal dander.
A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with negative pressure. B. Infection requires close contact; therefore, the door may remain open. C. Transmission is highly likely, so the client should wear a mask at all times. D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
Answer: D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. Options A and B: The door should remain closed, but a negative-pressure room is not necessary. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. Option C: It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask.
Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis? A. Myocardial Infarction B. Cirrhosis C. Peptic ulcer D. Pneumonia
Answer: D. Pneumonia Option D: A client with acute pancreatitis is prone to complications associated with respiratory system.
The clinic nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting? A. Spinal flexibility. B. Leg length disparity. C. Hypostatic blood pressure. D. Scoliosis.
Answer: D. Scoliosis. A check for scoliosis, a lateral deviation of the spine, is an important part of the routine adolescent exam. It is assessed by having the teen bend at the waist with arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is more common in female adolescents. Options A, B, and C are not part of the routine adolescent exam.
Which of the following antituberculosis drugs can damage the 8th cranial nerve? A. Isoniazid (INH) B. Para Aminosalicylic acid (PAS) C. Ethambutol hydrochloride (Myambutol) D. Streptomycin
Answer: D. Streptomycin Option D:Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.
The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? A. The patient must maintain a low-calorie diet. B. The patient must maintain a high protein/low carbohydrate diet. C. The patient should limit sweets and sugary drinks. D. The patient should limit fatty foods.
Answer: D. The patient should limit fatty foods. Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first? A. Raise the side rails on the bed B. Place the call bell within reach C. Instruct the client to remain in bed D. Have the client empty bladder
Answer: D: Have the client empty bladder The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, A and then B.
A nurse is reviewing a patient's past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply: A. Ciprofloxacin (Cipro) B. Sulfonamide C. Norfloxacin (Noroxin) D. Sulfamethoxazole and Trimethoprim (Bactrim) E. Isotretinoin (Accutane) F. Nitro-Dur patch
Answers: A, B, C, D, and E. Photosensitivity is an extreme sensitivity to ultraviolet (UV) rays from the sun and other light sources. A type of photosensitivity called Phototoxic reactions are caused when medications in the body interact with UV rays from the sun. Antiinfectives are the most common cause of this type of reaction.
A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? A. Partial thromboplastin time. B. Prothrombin time. C. Platelet count. D. Hemoglobin
Answers: A, B, and C. Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. Option D: The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein? Monitoring for infiltration behind the infant's elbow Applying arm boards to prevent bending at the elbows Checking both of the infant's pupils for dilation every hour Telling the parents why they cannot hold the infant during IV therapy
Applying arm boards to prevent bending at the elbows Rationale The extremity should be placed in an arm board so the child will not bend the elbow and restrict the flow of IV fluids. First the flow of fluid must be ensured; then the nurse should inspect often for signs of infiltration at the IV insertion site, not the elbow. Pupil responses are unrelated to dehydration and fluid replacement. The parents can be taught how to hold their infant while an IV infusion is being administered.
A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? Document the client's request in the medical record. Ask the client if this decision has been discussed with his healthcare provider. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Ask the client if this decision has been discussed with his healthcare provider.
The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? Withdraw the tube and apply additional lubricant to the tube. Encourage the client to bear down and continue to insert the tube. Remove the tube and check the client for a fecal impaction. Ask the client to relax and run a small amount of fluid into the rectum.
Ask the client to relax and run a small amount of fluid into the rectum.
A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition? Asking the parents to visit at mealtimes Having a nursing assistant feed the child Providing diversional activity at mealtimes Eliminating the child's between-meal snacks
Asking the parents to visit at mealtimes Rationale Dinner is frequently a family activity. Having the parents visit during meals may provide the child with additional emotional, social, and physical support, resulting in improved nutritional intake. The child will be resentful if fed by a staff member. Providing diversional activity at mealtimes may further inhibit the child's nutritional intake. Eliminating the child's between-meal snacks may not influence the child's overall intake; snacks may be preferred and will provide a source of nutrition.
On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? Assess her breastfeeding techniques to identify possible causes. Provide a nipple shield to keep the infant's mouth off the nipples. Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.
Assess her breastfeeding techniques to identify possible causes. Rationale The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.
A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress? Limiting discussions about the problem Providing information regarding medical care Teaching the client how to eliminate stress at home Assisting the client in developing new coping mechanisms
Assisting the client in developing new coping mechanisms Rationale Until the client learns new ways of coping with stress and anxiety, this pattern of behavior will continue. Learning new ways of coping with stress will help break this physiological pattern. Limiting discussion will avoid the problem. Providing information about medical care will reinforce the sick role. A certain amount of stress is present in everyday family situations; the elimination of stress is impossible.
A primary healthcare provider notes that all conventional treatment procedures have proved to be ineffective in managing a client's disorder. The primary healthcare provider decides to try an experimental treatment. The nurse ensures that the client has understood the implications of the new treatment plan thoroughly and then signs the client's consent form as a witness. Which basic healthcare ethic does the nurse follow in this situation? Justice Autonomy Beneficence Nonmaleficence
Autonomy Rationale Autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent. This ensures that the client is involved in the decision-making process appropriately. Justice refers to fairness. The given situation does not deal with fairness. Beneficence refers to taking positive actions to help others. This involves keeping the interests of the client before self-interest. Nonmaleficence is the avoidance of harm or hurt. Weighing the pros and cons of the new treatment plan would involve nonmaleficence.
A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention? Encouraging the client to try to walk Explaining to the client that there is nothing wrong Avoiding focusing on the client's physical symptoms Helping the client follow through with the physical therapy plan
Avoiding focusing on the client's physical symptoms Rationale The physical symptoms are not the client's major problem and therefore should not be the focus of care. This is a psychological problem, and the focus should be in this domain. Encouraging the client to try to walk is focusing on the physical symptom of the conflict; the client is not ready to give up the symptom. The disorder operates on an unconscious level but is very real to the client; saying there is nothing wrong denies feelings. Psychotherapy, not physical therapy, is needed at this time.
A nurse is recalling common terms that are used in health ethics. What does beneficence in health ethics refer to? Beneficence refers to the agreement to keep promises. Beneficence refers to taking positive actions to help others. Beneficence refers to the ability to answer for one's actions. Beneficence refers to avoiding harming or hurting an individual.
Beneficence refers to taking positive actions to help others. Rationale Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Accountability refers to the ability to answer for one's actions. Nonmaleficence refers to avoiding harming an individual.
A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? The responses to biofeedback have not been well established and may be a waste of time and money. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. Although biofeedback is easily learned, it is most often used to manage exacerbation of symptoms. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. Chemotherapy Repositioning Regular oral care Blood transfusion Radiation therapy
Chemotherapy Blood transfusion Radiation Therapy Rationale Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a client who is about to die and is receiving end-of-life care. End-of-life care comprises measures to make the client as comfortable as possible. It may include measures such as regular oral care and repositioning.
Which urodynamic study provides information on bladder capacity, bladder pressure, and voiding reflexes? Radiography Renal arteriography Electromyography (EMG) Cystometrography (CMG)
Cystometrography (CMG) Rationale Cystometrography (CMG) is an urodynamic study that provides information on bladder capacity, bladder pressure, and voiding reflexes. Radiography is a diagnostic test for clients with disorders of kidney and urinary system to screen for the presence of two kidneys, to measure kidney size, and to detect gross obstruction in kidneys or urinary tract. Renal arteriography is a diagnostic study used to determine renal blood vessel size and abnormalities. Electromyography (EMG) is an urodynamic study used to test the strength of perineal muscles in voiding.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? Decrease in red cell formation Rupture of emphysematous bullae Depression in the respiratory center Excessive drying of the respiratory mucosa
Depression in the respiratory center Rationale It is believed that clients with COPD should be given low concentrations of oxygen because a decreased oxygen blood level is the stimulus for breathing for these clients. However, the results of a recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen concentrations higher than 2 L/min. More research is needed before this theory is applied clinically. Prolonged hypoxia stimulates erythrocyte production; the goal of therapy is to relieve hypoxia. The pressure, rather than the concentration, at which oxygen is administered increases the risk of rupture of emphysematous bullae. The concentration of oxygen is unrelated to its humidification. To prevent its drying effects on secretions and the mucosa, oxygen should be humidified.
A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction? Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories help direct specific nursing activities. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.
Descriptive theories help direct specific nursing activities. Rationale Descriptive theories do not direct specific nursing activities. Instead, they help to explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.
In evaluating client care, which action should the nurse take first? Determine if the expected outcomes of care were achieved. Review the rationales used as the basis of nursing actions. Document the care plan goals that were successfully met. Prioritize interventions to be added to the client's plan of care.
Determine if the expected outcomes of care were achieved.
A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do? Reduce the intake of protein-rich foods Drink 8 ounces (240 mL) of water with meals Divide the daily caloric intake into six smaller meals Remain in an upright position for one hour after eating
Divide the daily caloric intake into six smaller meals Rationale The client's clinical manifestations are related to the dumping syndrome from the gastric bypass procedure. Smaller meals along with other interventions will help minimize this response. After gastric bypass, a bolus of hypertonic fluid enters the intestines before carbohydrates and electrolytes are diluted. Extracellular fluid is drawn into the bowel lumen; this causes a decrease in plasma volume, distention of the bowel lumen, and rapid intestinal transit. Protein intake should be increased, not decreased, to meet energy needs and promote healing. Fluids should be avoided at mealtimes because they increase the volume in the stomach and decrease the transit time of gastric contents moving from the stomach to the intestine, which contributes to dumping syndrome. An upright position decreases the transit time of gastric contents moving from the stomach to the intestines via gravity, which contributes to the dumping syndrome; clients may lie flat after eating for a short time.
List three safety precautions for the administration of antineoplastic chemotherapy.
Double check order with another nurse. Check for blood return before administration to ensure that medication does not go into tissue. Use a new IV site daily for peripheral chemotherapy. Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact with toxic substances.
When making the bed of a client who needs a bed cradle, which action should the nurse include? When making the bed of a client who needs a bed cradle, which action should the nurse include? Teach the client to call for help before getting out of bed. Keep both the upper and lower side rails in a raised position. Keep the bed in the lowest position while changing the sheets. Drape the top sheet and covers loosely over the bed cradle.
Drape the top sheet and covers loosely over the bed cradle.
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? Empty the client's urinary drainage bag. Draw up the irrigating solution into the syringe. Secure the client's catheter to the drainage tubing. Use aseptic technique to instill the irrigating solution.
Draw up the irrigating solution into the syringe.
The health care provider hands a neonate to a nurse immediately after birth. Which is the most appropriate action for the nurse to take next for this newborn? Perform an abbreviated physical assessment Administer oxygen until cyanosis disappears Cut the umbilical cord and attach an umbilical clip Dry the infant and provide skin-to-skin contact with the mother
Dry the infant and provide skin-to-skin contact with the mother Rationale The priority is preventing heat loss; drying the newborn prevents heat loss through evaporation, and skin-to-skin contact with the mother provides a warm environment while promoting attachment. These actions conserve the newborn's oxygen and glycogen reserves. Performing an abbreviated physical assessment is important but not a priority; assessment should be delayed until the infant is warm. Administering oxygen until cyanosis disappears is not necessary because warming the infant will reduce cyanosis if there is no respiratory obstruction. Cutting the umbilical cord and attaching an umbilical clip may be done after provisions have been made to prevent heat loss.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? Does not check capillary blood glucose as directed. Occasionally forgets to take daily prescribed medication. Cannot identify signs or symptoms of high and low blood glucose. Eats anything and does not think diet makes a difference in health.
Eats anything and does not think diet makes a difference in health.
Describe postoperative residual limb (stump) care (after amputation) for the first 48 hours.
Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb (stump) after 48 hours. Keep residual limb (stump) in extended position, and turn client to prone position three times a day to prevent flexion contracture.
List four common causes of fluid volume deficit.
Gastrointestinal causes, vomiting or diarrhea. GI suctioning decrease in fluid intake, increase in fluid output such as sweating, massive edema, or ascites
An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? Instructing the client to be quiet Allowing the client to act out until fatigue sets in Guiding the client from the room by gently holding the client's arm Giving the client one simple direction at a time in a firm, low-pitched voice
Giving the client one simple direction at a time in a firm, low-pitched voice Rationale Clients who are out of control are seeking control and typically respond to simple directions stated in a firm voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after an attempt at calming the client has failed.
Which statement about Henderson's theory of nursing care is correct? Henderson's self-care deficit theory focuses on the client's self-care needs. Henderson's theory is based on stress and the client's reaction to the stressor. Henderson's concept of the environment includes the suggestion that nurses do not need to know all about the disease process differentiated nursing from medicine. Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental.
Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the client: physiological, psychological, sociocultural, spiritual, and developmental. Rationale: Orem's self-care deficit theory focuses on the client's self-care needs. The Neuman systems model is based on stress and the client's reaction to the stressor. Nightingale's concept of the environment includes the suggestion that nurses do not need to know all about the disease process differentiated nursing from medicine
The nurse is in a situation where there is no premixed insulin. In fewer than 10 steps, describe the method of drawing up a mixed dose of insulin (regular with NPH).
Identify the prescribed dose and type of insulin per physician order; store unopened insulin in refrigerator. Opened insulin vials may be kept at room temperature. Draw up regular insulin first; rotate injection sites; may reuse syringe by recapping and storing in refrigerator.
The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation
Implementation Rationale The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.
An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? Diagnosis Evaluation Assessment Implementation
Implementation Rationale The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.
A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include? Purpose of bronchodilators Importance of meticulous oral hygiene Technique used in pursed-lip breathing Methods used to maintain a dust-free environment
Importance of meticulous oral hygiene Rationale Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection. Bronchodilators will not prevent infection; they dilate the bronchi. Pursed-lip breathing will not prevent infection; it promotes gas exchange in the alveoli and facilitates more effective exhalation. It is impossible to maintain a dust-free environment.
An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment and collecting a health history from the client, what action should the nurse take next? Reassess the client and allow the friend to stay. Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line. Assign the client to a private room and put a cool cloth on the client's forehead. Place the client in a dimly lit room and perform a neurologic assessment every 15 minutes.
Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line. Rationale 4-methylenedioxy-methamphetamine (Ecstasy) is a drug of abuse that has both stimulant and hallucinogenic properties. Stimulants have the ability to cause dehydration by increasing activity and diaphoresis via increased adrenalin release. The client is displaying symptoms of dehydration; the healthcare provider must be informed so an IV can be prescribed. Letting the friend stay and reassessing the client in one hour are inappropriate; the client's vital signs indicate the need for immediate attention. Placing the client in a private room with a cool cloth on the head is inappropriate; the client's vital signs are indicative of a problem. Performing a neurologic assessment every 15 minutes is inappropriate at this time. The client's vital signs indicate a need for immediate medical attention.
A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period? Offering psychological support Monitoring the client's fluid balance Keeping the client's respiratory passages patent Providing a pad and pencil for writing messages
Keeping the client's respiratory passages patent Rationale A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.
A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? Ketoacidosis Somogyi phenomenon Hypoglycemic reaction Hyperosmolar nonketotic coma
Ketoacidosis Rationale Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.
What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline? Massaging the uterine fundus Helping the client to the bathroom Assessing the peripad for the amount of lochia Administering intramuscular methylergonovine (Methergine) 0.2 mg
Massaging the uterine fundus Rationale A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.
What is the priority nursing intervention for a 6-month-old infant with bronchiolitis? Discouraging parental visits to conserve energy Monitoring skin color, anterior fontanel, and vital signs Wearing gown, cap, mask, and gloves when rendering care Promoting stimulating activities to meet developmental needs
Monitoring skin color, anterior fontanel, and vital signs Rationale Continuous assessments are vital in determining the infant's oxygenation and hydration status and responses to the disease process. The infant needs the parents' presence to fulfill the developmental goal of infancy, the establishment of trust. Respiratory syncytial virus is the most common cause of bronchiolitis in an infant. Contact precautions are recommended for an infant with bronchiolitis; airborne precautions are not necessary. The infant is too ill to be involved in stimulating activities; energy should be conserved and oxygen demands kept to a minimum.
Which nurse participates in the development of nursing policies and procedures? Nurse educator Clinical nurse specialist Certified nurse-midwife Certified registered
Nurse educator
Which is an appropriate action for the registered nurse regarding assisted suicide? Nurses may have an open attitude toward the client's end of life. Nurses' participation in assisted suicide violates the code of ethics. Nurses may listen to the client's expressions of fear and to attempt to control the client's pain. Nurses can participate in assisted suicide only if the individual could make an oral and written request.
Nurses' participation in assisted suicide violates the code of ethics. Rationale According to the ANA, a nurse's participation in assisted suicide will violate their code of ethics. According to the American Association of Colleges of Nursing (AACN) and the International Council of Nurses', the nurse may have an open attitude toward the client's end of life. According to the American Association of Colleges of Nursing (AACN) and the International Council of Nurses', nurses may listen to the client's expressions of fear and to attempt to control the client's pain. According to the Oregon Death with Dignity Act (1994) the primary health care provider in the state of Oregon can participate in assisted suicide only if an individual with terminal disease makes an oral and written request to end his or her life in a humane and dignified manner.
Which psychosocial nursing actions are appropriate when providing client care after a community disaster? Select all that apply. Performing triage of injuries Administering first aid to wounds Offering choices whenever possible Establishing rapport through active listening Requesting assistance from crisis counselors
Offering choices whenever possible Establishing rapport through active listening Requesting assistance from crisis counselors
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes
Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques Rationale Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.
A child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. What is the priority nursing intervention? Having the child rest as much as possible Checking the child's eosinophil count daily Preventing exposure of the child to infection Offering nothing by mouth to the child except oral medications
Preventing exposure of the child to infection Prednisone reduces the child's resistance to certain infectious processes and, as an antiinflammatory drug, masks infection. The child will self-limit activity depending on respiratory status. The eosinophil count is often consistently increased in children with asthma. The child will need adequate hydration to help loosen and expel mucus.
Which statement is true regarding the Hering-Breuer reflex? Increases tidal volume Decreases respiratory rate Prevents overdistension of the lungs Reduces the number of functional alveoli
Prevents overdistension of the lungs Rationale The Hering-Breuer reflex prevents overdistention of the lungs. An increase in hydrogen ion concentration will cause an increase in the tidal volume via central chemoreceptors. A decrease in the hydrogen ion concentration will cause a decreased respiratory rate via peripheral chemoreceptors. The Hering-Breuer reflex does not cause a reduction in the number of functional alveoli.
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? Temperature increases from 98.8 to 99.0 F. Pulse rate decreases from 78 to 52 beats/min. Respiratory rate increases from 16 to 24 breaths/min. Blood pressure increases from 110/84 to 118/88 mm/Hg.
Pulse rate decreases from 78 to 52 beats/min.
Identify the peak action time of the following types of insulin: rapid-acting regular insulin, intermediate-acting insulin, and long-acting insulin.
Rapid-acting regular insulin: 2 to 4 hours; immediate-acting insulin: 6 to 12 hours; long-acting insulin: 14 to 20 hours
Which domain of the nursing intervention phase includes electrolyte and acid-base management? Domain 1 Domain 2 Domain 3 Domain 4
Rationale Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiologic complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.
What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment? Reality orientation Behavioral confrontation Reflective communication Reminiscence group therapy
Reality orientation Rationale Reality orientation is generally helpful for clients exhibiting mild cognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety. Behavioral confrontation is not therapeutic because it may cause frustration and increase psychomotor agitation in a client with cognitive impairment. Reflective communication is a technique in which the nurse restates or repeats the client's statements; it can be used to clarify thoughts but may also lead to frustration when the approach is overdone. Reminiscence group therapy is helpful with severely confused, disorganized clients because it reinforces identity, acknowledges what was significant, and often compensates for the dullness of the present.
The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? Review the steps in the procedure manual. Ask another nurse to assist while implementing the procedure. Follow the agency's policy and procedure. Refuse to perform the task that is beyond the nurse's experience.
Refuse to perform the task that is beyond the nurse's experience.
Kidneys also...
Regulates sodium and potassium levels and maintains the pH level by excreting or maintaining hydrogen ions and bicarbonate4. Excretes metabolic wastes and toxic substances, also responsible for manufacturing the hormone erythropoietin (EPO).
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site
Removing the catheter within 24 hours Rationale Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? Stimulating crying Suctioning the airway Using an Ambu bag with oxygen support Placing the infant in the reverse Trendelenburg position
Suctioning the airway Rationale Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.
A nursing student is listing the different levels of the health care services pyramid. Under which type of health care services should the nursing student include subacute care? Tertiary care Continuing care Restorative care Secondary acute care
Tertiary care
A nurse is teaching a parent about the different temperaments that a child may display. What characteristics does a slow-to-warm up child display? Select all that apply. The child adapts slowly with frequent communication. This child is regular and predictable in his or her habits. The child is highly active, irritable, and irregular in his or her habits. The child reacts with mild but passive resistance to novelty. The child reacts negatively and with mild intensity to new stimu
The child reacts with mild but passive resistance to novelty. The child reacts negatively and with mild intensity to new stimuli The child adapts slowly with frequent communication.
When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? The drainage tubing is secured over the siderail. The clamp on the urinary drainage bag is open. There are no dependent loops in the drainage tubing. The urinary drainage bag is attached to the bed frame.
The clamp on the urinary drainage bag is open.
Hyponatremia S/S
Anorexia, N/V, Weakness, Lethargy, Confusion, Muscle cramps, Twitching, Seizures
List four common causes of fluid volume overload.
Heart failure, renal failure; cirrhosis; excess ingestion of table salt or overhydration with sodium-containing fluids
Hyperphosphatemia Tx
Admin aluminum hydroxide with meals to bind phosphorous; Dialysis may be required if renal failure is underlying cause
Hypomagnesemia S/S
Anorexia, Distention, Neuromuscular irritability, Depression, Disorientation
Acronym ROME
The acronym ROME can help you remember: respiratory, opposite, metabolic, equal.
After transurethral resection of the prostate gland (TURP), hematuria should subside by what postoperative day?
The fourth day
A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? "The cause is abnormal configurations of the veins." "The cause is incompetent valves of superficial veins." "The cause is decreased pressure within the deep veins." "The cause is atherosclerotic plaque formation in the veins."
"The cause is incompetent valves of superficial veins." Rationale Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.
What does the nurse educate the mother of a toddler to do in order to promote safety? "Throw plastic grocery bags away." "Fill the crib with large, stuffed toys." "Put pacifiers around the neck of the toddler." "Place the toddler to sleep on his or her back."
"Throw plastic grocery bags away."
1. Which individual is at greatest risk for developing hypertension? A. 45-year-old African American attorney B. 60-year-old Asian American shop owner C. 40-year-old Caucasian nurse D. 55-year-old Hispanic teacher
1. Answer: A: 45-year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
Acid base involves 3 systems
1. Chemical buffer system 2. Kidneys 3. Lungs
Acid-base balance is determined by the hydrogen ion concentration in body fluids.
1. Normal range is 7.35 to 7.45 expressed as the pH 2. A pH level below 7.35 indicates acidosis. 3. A pH level above 7.45 indicates alkalosis. 4. Measurement is made by examining ABGs
What is the maximum recommended intramuscular dose for medications in preschoolers? 0.5 mL 1.0 mL 1.5 mL 2.0 mL
1.0 mL
What is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number. cm
10 cm In adolescents, the maximum length for insertion of an enema tube is 10 cm.
A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? 1. Giving oil-retention enemas daily for two days preoperatively 2. Administering cleansing enemas and then neomycin 3. Having a Sengstaken-Blakemore tube at the bedside 4. A high-protein and high-carbohydrate regular diet for two days preoperatively
2. Administering cleansing enemas and then neomycin Rationale After the bowel is cleansed, neomycin is given to decrease gram-negative bacteria in the colon, which should limit postoperative infection. Oil-retention enemas are used to alleviate constipation; oil-retention enemas are not prescribed before surgery because they contaminate the bowel with oil. A Sengstaken-Blakemore tube is used for a client with ruptured esophageal varices, not for a client having a hemicolectomy. A diet to decrease bulk and empty the colon generally is prescribed; usually it is a clear liquid diet.
What is the normal value of functional residual capacity? 2.5 L 3.5 L 4.5 L 6.0 L
2.5 L Rationale The normal value of functional residual capacity is 2.5 L. The normal value of inspiratory capacity is 3.5 L. The normal value of vital capacity is 4.5 L.The normal value of total lung capacity is 6.0 L.
A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? 1. Decrease in urine output 2. Increase in pulse strength 3. Shrinkage of the tumor on scanning 4. Increase in the quantity of white blood cells (WBCs)
3. Shrinkage of the tumor on scanning Rationale Brachytherapy, in which isotope seeds are implanted in the tumor, interferes with cell multiplication, which should control the growth and metastasis of cancerous tumors. Radiation affects healthy as well as abnormal cells; urinary output will increase with successful therapy. With brachytherapy of the bladder, increase in pulse strength is not a sign of success. Bone marrow sites may be affected by radiation, resulting in a reduction of WBCs.
What is the normal value of inspiratory reserve volume? 0.5 L 1.0 L 1.5 L 3.0 L
3.0 L Rationale The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.
The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which blood glucose levels should the nurse identify as hypoglycemia? 68 mg/dL (3.8 mmol/L) 78 mg/dL (4.3 mmol/L) 88 mg/dL (4.9 mmol/L) 98 mg/dL (5.4 mmol/L)
68 mg/dL (3.8 mmol/L) Rationale Normal blood glucose level for an adult is 72-108 mg/dL (4-6 mmol/L). Clients who have blood glucose levels below 72 mg/dL (4 mmol/L) may experience hypoglycemia; 78 mg/dL (4.3 mmol/L), 88 mg/dL (4.9 mmol/L), and 98 mg/dL (5.4 mmol/L) are normal blood glucose levels.
Write two nursing diagnoses for the client suffering from anemia.
Activity intolerance and ineffective tissue perfusion
Hypomagnesemia causes
Alcoholism Malabsorption Diabetic ketoacidosis Prolonged gastric suction Diuretics
A client reports an absence of menstruation to the nurse. Which condition does the nurse suspect? Gonorrhea Amenorrhea Dysmenorrhea Ectopic pregnancy
Amenorrhea Rationale An absence of menstruation indicates amenorrhea. Gonorrhea is a sexually transmitted disease. Dysmenorrhea is with painful menstruation associated with abdominal cramps. The formation of a fetus outside the uterus, such as a Fallopian tube, indicates ectopic pregnancy.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? Assessment. Analysis. Implementation. Evaluation.
Analysis.
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A. Client must be NPO before the examination B. Enema to be administered prior to the examination C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D. No special orders are necessary for this examination
Answer: D: No special orders are necessary for this examination No special preparation is necessary for this examination.
respiratory alkalosis
Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.
A client is demonstrating a positive Chvostek's sign. What action should the nurse take? Observe the client's pupil size and response to light. Ask the client about numbness or tingling in the hands. Assess the client's serum potassium level. Restrict dietary intake of calcium-rich foods.
Ask the client about numbness or tingling in the hands.
A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take? Loosen the dressing slightly. Notify the primary healthcare provider. Assess the pulses distal to the dressing. Have the client flex the joints of the right leg
Assess the pulses distal to the dressing. Rationale Assessing the circulatory status of the extremity will determine whether the dressing is too tight. Loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated. Notifying the primary healthcare provider is premature; the primary healthcare provider should be notified if circulation to the leg is compromised. Having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated. The leg should remain extended for several hours.
Which condition results in visual distortion? Myopia Hyperopia Presbyopia Astigmatism
Astigmatism Rationale Astigmatism is caused by unevenness in the cornea; this condition results in visual distortion. Myopia (nearsightedness) results in the blurred vision of distant objects. Hyperopia (farsightedness) results in the clear vision of distant objects and the blurred vision of close objects. Presbyopia is a condition related to older adults; this condition results in an inability to focus on near objects.
A nurse in the pediatric clinic is assessing an 8-year-old child who has had asthma since infancy. What clinical finding requires immediate intervention? Barrel chest Audible wheezing Heart rate of 105 beats/min Respiratory rate of 30 breaths/min
Audible wheezing Rationale Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly compromised, and this requires immediate medical intervention. Barrel chest is a sign of chronic asthma. Repeated attacks result in a fixed hyperaerated thoracic cavity; this clinical finding does not require intervention. A heart rate of 105 beats/min is expected in an 8-year-old child, as is a respiratory rate of 30 breaths/min.
Hypermagnesemia Tx
Avoid magnesium-based antacids and laxatives; Restrict dietary intake of foods high in Mg+
A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent? Battery Invasion of privacy False imprisonment Defamation of character
Battery Rationale Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary healthcare provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.
Describe nursing care for the client who is experiencing phantom pain after amputation.
Be aware that phantom pain is real and will eventually disappear. Administer pain medication; phantom pain responds to medication.
A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? Brick red Pale pink Light gray Dark purple
Brick red Rationale Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.
A nurse is caring for a 7-year-old child with severe burns who has extensive eschar formation on the arms. What is the priority nursing intervention? Removing blisters Checking radial pulses Maintaining respiratory isolation Performing range-of-motion exercises
Checking radial pulses Rationale The radial pulses are a reflection of how the child is adapting to the eschar formation. Eschar is rigid and may restrict circulation, leading to loss of perfusion to the limbs. Blisters are a protective adaptation and should not be disturbed. There is no information to indicate that the child has a respiratory infection. Although range-of-motion exercises are important, adequate arterial perfusion is the priority.
Describe the method of collecting the trough and peak blood levels of antibiotics.
Collection of peak: Draw blood 30 minutes after administration of antibiotic. Collection of trough: draw blood 30 minutes before administration of antibiotic.
A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? Continue gabapentin. Discontinue ibuprofen. Add aspirin to the protocol. Add oral methadone to the protocol.
Continue gabapentin.
List five important teaching aspects for clients who are beginning corticosteroid therapy.
Continue medication until weaning plan is begun by physician; monitor serum potassium, glucose, and sodium frequently; weigh daily, and report gain of >5 lb/wk; monitor BP and pulse closely; teach symptoms of Cushing syndrome.
After the urinary catheter is removed in the TURP client, what are three priority nursing actions?
Continued strict I&O. Continued observations for hematuria. Inform client burning and frequency may last for a week.
Hypophosphatemia Tx
Correct underlying cause; Admin PO replacement of phosphates with Vitamin D
FYI: Creatinine
Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test, and they are normally in a 1:20 ratio.
A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Increase left ventricular filling and improve cardiac output Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow
Decrease the workload on the heart and promote maximum coronary artery filling Rationale With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and therefore oxygen to reach cardiac muscle; this increases myocardial efficiency. Increasing left ventricular filling increases the workload of the heart. Oxygenation of vital organs must be maintained. Decreasing oxygen to vital organs of the body may interfere with their ability to function. Increasing venous return to the right atrium increases the workload of the heart.
Lab results in FVE
Decreased BUN• Decreased hemoglobin and hematocrit• Decreased serum osmolality• Decreased urine osmolality and specific gravity
Which drug can cause diabetes insipidus? Cabergoline Metyrapone Demeclocycline Aminoglutethimide
Demeclocycline Rationale Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.
Determine the following acid-base disorders: A. pH 7.50, PCO 2 30, HCO3 28 B. pH 7.30, PCO 2 42, HCO3 20 C. pH 7.48, PCO 2 42, HCO3 32 D. pH 7.29, PCO 2 55, HCO3 28
Disorders A. Respiratory alkalosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis
Identify two nursing interventions for the client on hemodialysis.
Do not take BP or perform venipuncture on the arm with the atrioventricular (AV) shunt, fistula, or graft. Assess access site for thrill and bruit.
In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? Elevate the head of the bed and attempt to palpate the site again. Document the presence and volume of the pulse palpated. Use a thigh cuff to measure the blood pressure in the leg. Record the presence of pitting edema in the inguinal area.
Document the presence and volume of the pulse palpated.
Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation? Domain 1 Domain 2 Domain 3 Domain 4
Domain 2 Rationale Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.
According to Piaget during which developmental state is the pediatric client egocentric? Infancy Adolescence Early childhood Middle childhood
Early childhood Rationale According to Piaget, the early childhood (toddler) and preschool-age child are both egocentric [1][2]. Infancy, adolescence, and middle childhood are not characterized as being egocentric, according to Piaget.
What bowel sound disruptions occur with an intestinal obstruction?
Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or absent bowel sounds
A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? Review the client's medical record for an advance directive. Determine if a do-not-resuscitate prescription has been obtained. Document that the client is being discharged against medical advice. Evaluate the client's mental status for competence to refuse treatment.
Evaluate the client's mental status for competence to refuse treatment.
Hypokalemia S/S
Fatigue, Anorexia, N/V, Muscle weakness, Decreased GI motility, Dysrhythmias, Paresthesia, Flat T waves on ECG
List four essential elements of a teaching plan for clients with frequent urinary tract infections.
Fluid intake 3 L/day; good handwashing; void every 2 to 3 hours during waking hours; take all prescribed medications; wear cotton undergarments.
Hyponatremia treatment
Fluid restriction If fluid restriction is not effective, give IV saline solution very slowly
A nursing student is listing examples of active and passive health promotion strategies. Which strategy is an example of a passive health promotion strategy? Weight-reduction program Smoking-cessation program Drug abuse prevention strategy Fluoridation of municipal drinking water
Fluoridation of municipal drinking water Rationale Passive strategies of health promotion help people benefit from the activities of others without direct involvement. The fluoridation of municipal drinking water is an example of a passive health promotion strategy. Active strategies of health promotion require clients to adopt specific programs for improving health. Weight-reduction programs, smoking-cessation programs, and drug abuse prevention strategies are examples of active health promotion activities.
Hypermagnesemia S/S
Flushing, Hypotension, Drowsiness, Lethargy, Hypoactive reflexes, Depressed respirations, Bradycardia
A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? Focusing on the present Identifying past stressors Discussing a referral for psychotherapy Exploring the client's history of mental health problems
Focusing on the present
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? Amount of liquid protein supplements consumed daily. Foods and liquids consumed during the past 24 hours. Usual weekly intake of milk products and red meats. Grains and legume combinations used by the client.
Foods and liquids consumed during the past 24 hours.
A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? Avoiding leg massages Frequent repositioning of client Increasing fiber content in food Encouraging weight-bearing exercises
Frequent repositioning of client Rationale Frequent repositioning of the client in bed or wheelchair will relieve pressure points, thereby decreasing pressure ulcers. Avoiding leg massages will decrease the risk of embolism but does not relieve pressure ulcers. Increased intake of dietary fiber will relieve the immobilized client of constipation. Weight-bearing exercises will prevent the immobilized client from developing muscular atrophy or loss of calcium from the bone.
What are the common food intolerances for clients with cholelithiasis?
Fried, spicy, and fatty foods
List four topics you would cover when teaching an immunosuppressed client about infection control.
Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily hygiene to prevent spread of microorganisms.
List three of the most common joints that are replaced.
Hip, knee, finger
List four groups who have a high risk for contracting hepatitis.
Homosexual males, IV drug users, those who have had recent ear piercing or tattooing, and health care workers
List five symptoms of hypoglycemia.
Hunger, lethargy, confusion, tremors or shakes, sweating
Hypercalcemia causes
Hyperparathyroidism Malignant bone disease Prolonged immobilization Excess calcium supplementation
State three symptoms of hyperthyroidism and three symptoms of hypothyroidism.
Hyperthyroidism: weight loss, heat intolerance, diarrhea; hypothyroidism: fatigue, cold intolerance, weight gain
Respiratory vs Metabolic
In metabolic disorders, the PCO2 is normal, and the arrows for pH and HCO3 point in the same direction or are equal
Respiratory vs Metabolic
In respiratory disorders, the HCO3 is normal, and the arrows for pH and PCO2 point in opposite directions.
A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? Bradycardia. Increase in pulse rate. Peripheral vasodilation. Increase in cardiac output.
Increase in pulse rate.
What is the function of limbic system? Influence emotional behavior Regulate autonomic functions Facilitate automatic movements Relay sensory and motor inputs for cerebrum
Influence emotional behavior Rationale Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.
Describe the use of leucovorin.
Leucovorin is used as an antidote with methotrexate to prevent toxic reactions.
What discharge instructions should be given to a client who has had urinary calculi?
Maintain high fluid intake of 3 to 4 L/day. Pursue follow-up care (stones tend to recur). Follow prescribed diet based on calculi content. Avoid supine position.
A client undergoes removal of a pituitary tumor through a transsphenoidal approach. What should the nurse implement postoperatively? Provide oral hygiene and include brushing the teeth Encourage the client to deep breathe and cough frequently Maintain the head of the bed at a 30-degree angle continuously Continue giving nothing by mouth until the nasal packing is remove
Maintain the head of the bed at a 30-degree angle continuously
A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should place the client's affected extremity in which position? External rotation Slight hip flexion Moderate abduction Anatomic body alignment
Moderate abduction Rationale Abduction reduces stress on anatomic structures and maintains the head of the femur in the acetabulum. External rotation places stress on the acetabulum and the head of the femur. Hip flexion may dislodge the head of the femur from the acetabulum. Functional alignment places stress on the bone, soft tissue, and nail plate; it can cause damage and dislocation of the head of the femur.
Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery? Placing in the high Fowler position Administering the prescribed sedative Positioning on the same side as the shunt Monitoring for increasing intracranial pressure
Monitoring for increasing intracranial pressure Rationale The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid in the head; the accumulated fluid causes an increase in intracranial pressure, which in turn leads to brainstem hypoxia. Positioning the infant flat helps prevent complications resulting from too-rapid reduction of intracranial fluid. Although pain management is essential to minimize an increase in intracranial pressure, sedation is contraindicated because it will mask the infant's level of consciousness. The infant is positioned on the side opposite the shunt to prevent pressure on the valve and incision area.
What is the priority nursing intervention during the admission of a primigravida in labor? Monitoring the fetal heart rate Asking the client when she ate last Obtaining the client's health history Determining whether the membranes have ruptured
Monitoring the fetal heart rate Rationale Determining fetal well-being supersedes all other measures; if the fetal heart rate is absent or persistently decelerating, immediate intervention is required. The health history, including the client's last meal and whether the membranes have ruptured, may be taken once fetal well-being has been established.
Describe the physical appearance of clients who have Cushing syndrome.
Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin
Hypercalcemia S/S
Muscle weakness, Constipation, Anorexia, N/V, Polyuria, Polydipsia, Neurosis, Dysrhythmias,
Identify the categories of drugs commonly used to treat arthritis.
NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe)
The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily Give 1 L of 0.9% normal saline (NS) bolus over 4 hours Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr No prescription change
No prescription change Rationale The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client. Increasing the furosemide or giving intravenous fluid to this client could result in a fluid imbalance.
What is the only IV fluid compatible with blood products?
Normal Saline
Cite the normal ABGs for the following: A. pH B. PCO 2 C. HCO3
Normal values A. 7.35 to 7.45 pH B. 35 to 45 mm Hg PCO 2 C. 21 to 28 mEq/L HCO3
What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?
Notify physician stat, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure.
The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? Notify the primary healthcare provider immediately Apply a warm, moist compress to the incision site Increase the intravenous fluid rate by 20 mL/hr Monitor vital signs more frequently
Notify the primary healthcare provider immediately
Fluid Volume Deficit
Occurs when the body loses water and electrolytes isotonically—that is, in the same proportion as exists in the normal body fluid• Serum electrolyte levels remain normal• Dehydration: state in which the body loses water and serum sodium levels increase
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis? Padding the side rails of the crib Arranging for a quiet, cool room Placing a tracheostomy unit by the bedside Obtaining a recliner so a parent can stay
Placing a tracheostomy unit by the bedside Rationale The priority is a patent airway; the equipment needed to ensure a patent airway must be immediately available. Although padding the rails of the crib is helpful, it is not the priority. Arranging for a quiet, cool room is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Although it is appropriate to obtain a recliner so a parent may stay, this is not the priority.
List five symptoms of hyperglycemia.
Polydipsia, polyuria, polyphagia, weakness, weight loss
What measures should the nurse encourage female clients to take to prevent osteoporosis?
Possible estrogen replacement after menopause, high calcium and vitamin D intake beginning in early adulthood, calcium supplements after menopause, and weight-bearing exercise
Which statement is true about prescriptive theories? Prescriptive theories are action-oriented. Prescriptive theories help to explain client assessment. Prescriptive theories focus on a specific field of nursing. Prescriptive theories are the first level of theory development.
Prescriptive theories are action-oriented. Rationale Prescriptive theories are action-oriented. They test the validity and predictability of a nursing intervention. These theories address nursing interventions for a phenomenon, describe the conditions under which the prescription occurs, and predict the consequences. Descriptive theories help to explain client assessment. A middle-range theory tends to focus on a specific field of nursing. Descriptive theories are the first level of theory development.
Which key feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence
Presence of nonintact skin Rationale The skin is nonintact in stage 2 of pressure ulcers. Sinus tracts may develop during stage 4 of pressure ulcers. The subcutaneous tissue becomes damaged or necrotic during stage 3 of pressure ulcers. A reddened area over a bony surface occurs in stage 1 of pressure ulcers
Which synovial joint movement is involved in turning the client's palm downward? Eversion Inversion Pronation Supination
Pronation
List four nursing interventions for care of the client with Hodgkin disease.
Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support to client and family.
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do? Provide a means for the client to write Allow the client more time for articulation Use visual clues, such as gestures and objects Face the client and speak slowly and distinctly
Provide a means for the client to write
On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? Remind the client to turn every two hours while lying in bed. Provide warm prune juice before the client goes to bed at night. Teach the client to splint the incision while walking to the bathroom. Administer an analgesic before the client attempts to defecate.
Provide warm prune juice before the client goes to bed at night.
Which step should the nurse follow for the administration of ear drops in children of 4 to 5 years of age? Pull the auricle up and out. Place the cotton ball into innermost part of canal. Keep the child in side-lying position for 10 to 15 minutes. Instill prescribed drops while holding dropper 3 cm above ear canal.
Pull the auricle up and out. Rationale When administering ear drops to preschoolers, the nurse should pull the auricle up and out. The cotton ball is placed into the outermost part of the ear canal. The toddler is kept in side-lying position for 2 to 3 minutes, and then the prescribed drops are instilled by holding the dropper 1 cm above the ear canal.
List five symptoms indicative of colon cancer.
Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss
Hyperphosphatemia S/S
Short-term: tetany symptoms; Long-term: phosphorous precipitation in nonosseous sites
List four nursing interventions for the client with a hiatal hernia.
Sit up while eating and for 1 hour after eating. Eat frequent, small meals. Eliminate foods that are problematic.
Which should the nurse encourage for the adolescent client diagnosed with a chronic illness to achieve independence from family? Using coping skills Wearing make-up Buying stylish clothes Socializing with peers
Socializing with peers Rationale Socialization with peers should be encouraged[1][2] for adolescent clients diagnosed with a chronic illness to achieve independence from family. Use of coping skills helps the adolescent develop a personal identity. Wearing make-up and buying stylish clothes allows the adolescent to learn through abstract thinking.
The nurse should understand the effects of internal and external variables to plan and deliver individualized care. Which variable is an example of an external variable? Spiritual factors Developmental issues Socioeconomic factors Perception of functioning
Socioeconomic factors
What actions should the nurse take if a hemolytic transfusion reaction occurs?
Turn off transfusion. Infuse normal saline using a new bag and new tubing. Take temperature. Send blood being transfused to laboratory. Obtain urine sample. Keep vein patent with normal saline.
Which type of diabetes always requires insulin replacement?
Type 1
Which type of diabetes sometimes requires no medication?
Type 2
Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? The nurse will provide client instruction for daily foot care. The client will demonstrate proper trimming toenail technique. Upon discharge, the client will list three ways to protect the feet from injury. After instruction, the nurse will ensure the client understands foot care rational
Upon discharge, the client will list three ways to protect the feet from injury.
List the symptoms of upper and lower GI bleeding.
Upper GI: melena, hematemesis, tarry stools; Lower GI: bloody stools, tarry stools; Common to both: tarry stools
List three interventions for clients with a tendency to bleed.
Use a soft toothbrush, avoid salicylates, do not use suppositories.
Describe care of invasive catheters and lines.
Use strict aseptic technique. Change dressings two or three times per week or when soiled. Use caution when piggybacking drugs; check purpose of line and drug to be infused. When possible, use lines to obtain blood samples to avoid "sticking" client.
An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip? Changing the infant's position often Using modified techniques for feeding Monitoring the infant's daily intake and output Keeping the infant's head elevated during feedings
Using modified techniques for feeding Rationale Infants with a cleft in the lip are unable to suck like other newborns because they cannot form a vacuum to draw milk from the nipple. Frequent position changes are common for all infants, not just ones with cleft lip. Monitoring of intake and output is not necessary because hydration is maintained once a feeding method has been established. All infants should be fed with the head elevated to avoid pooling of milk in the mouth, which could result in aspiration.
List three problems associated with immobility.
Venous thrombosis, urinary calculi, skin integrity problems.
Hyponatremia causes
Vomiting Diuretics Excessive administration of dextrose and water IVs Burns, wound drainage Excessive water intake SIADH
Causes of FVD
Vomiting• Diarrhea• GI suctioning• Sweating• Inadequate fluid intake• Massive edema, as in initial stage of major burns• Ascites• Older adults forgetting to drink
Identify pain relief interventions for clients with arthritis.
Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? Hydrogel. Exudate absorber. Wet to moist dressing. Transparent adhesive film.
Wet to moist dressing.
To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? Can you describe where your pain is the most severe? What is your pain intensity on a scale of 1 to 10? Is your pain best described as aching, throbbing, or sharp? Which activities during a routine day are impacted by your pain?
Which activities during a routine day are impacted by your pain?
A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? Witness the client's signature on the consent form. Verify the client's consent with the healthcare provider. Notify the healthcare provider that the client is ready for the procedure. Document that the client has given consent for the needle aspiration.
Witness the client's signature on the consent form.
adrenal glands and acid/base balance
a pair of endocrine glands that sit just above the kidneys and secrete aldosterone when the body's blood pressure (BP) becomes low, resulting in sodium retention (leading to water retention), thereby increasing BP and potassium excretion to maintain homeostasis.
Hypokalemia Tx
• Administer potassium supplements orally or IV.• Oral forms of potassium are unpleasant tasting and are irritating to the GI tract (do not give on empty stomach; dilute).• Never give IV bolus; must be well diluted.• Assess renal status (i.e., urinary output) before administering.• Encourage foods high in potassium (e.g., bananas, oranges, cantaloupes, avocados, spinach, potatoes).
Hypokalemia causes
• Diuretics• Diarrhea• Vomiting• Gastric suction• Steroid administration• Hyperaldosteronism• Amphotericin B• Bulimia• Cushing syndrome
Tx in FVE
• Diuretics• Fluid restriction• Strict I&O• Sodium-restricted diet• Weighed daily• Serum K+ monitored
Causes of FVE
• Heart failure (HF)• Renal failure• Cirrhosis, liver failure• Excessive ingestion of table salt• Overhydration with sodium-containing fluid• Poorly controlled IV therapy, especially in young and old clients
Hyperkalemia causes
• Hemolyzed serum sample produces pseudohyperkalemia• Oliguria• Acidosis• Renal failure• Addison disease• Multiple blood transfusions
