HESI Reduce Risk Potential Quiz

The nurse performing a screening test for tuberculosis (TB) explains that which may be the cause of a positive reaction?

A previous exposure to the organism Rationale: The presence of antibodies indicates past exposure to or infection with an organism that may be presently dormant. A positive response does not indicate the status of the immune system. A positive response does not necessarily indicate active TB infection; a purified protein derivative (PPD) test administered to an individual with active TB may cause a severe reaction. A positive PPD test does not predict forthcoming exposure or infection; it only indicates past exposure to the organism.

A client receiving treatment via intrathecal therapy reports a headache and neck stiffness. Upon assessment, the client's body temperature is 103°F (39.4°C). Which infection would the nurse suspect?

Meningitis Rationale: An infection in a client receiving intrathecal therapy may occur due to lack of asepsis during the administration. The client may also exhibit neurological and systemic signs of infections such as meningitis, which is manifested by a headache, stiff neck, and body temperature of 103°F (39.4°C). Giardiasis is an intestinal infection caused by Giardia lamblia. Although fever can occur with pneumonia, pneumonia is primarily a lung infection. Furunculosis is a bacterial infection of the skin.

Which laboratory test will be elevated in a client with inflammatory arthritis?

Erythrocyte sedimentation rate (ESR) The ESR measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. An elevated ESR (20 mm/hr) indicates inflammation or infection somewhere in the body. The ESR is chronically elevated with inflammatory arthritis. Leukocytes will be elevated when a bacterial infection is present. Hemoglobin and hematocrit are not used to determine the presence of inflammation. Blood urea nitrogen and creatinine levels are used to determine renal function.

Which information would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain?

It assesses myocardial ischemia and perfusion. Rationale: Thallium imaging is used to assess myocardial ischemia or necrotic muscle tissue related to angina or myocardial infarction. Necrotic or scar tissue does not extract the thallium isotope, leading to cold spots. Action of the heart valves is available from an echocardiogram or, if indicated, from a cardiac catheterization with an angiography. Visualization of the ventricular systole and diastole is determined by cardiac angiography. Identifying the adequate cardiac conduction is determined by an electrocardiogram.

The arterial blood gas for a 3-month-old infant with diarrhea showed that the pH is 7.30, Pco 2 is 35 mm Hg, and HCO 3- is 17 mEq/L (17 mmol/L). Which would the nurse conclude has developed?

Metabolic acidosis Rationale: The blood pH indicates acidosis; the bicarbonate (HCO 3-) level is further from the expected range than is the partial pressure of carbon dioxide (Pco 2), indicating a metabolic origin (losses from diarrhea), not a respiratory origin. The blood pH indicates acidosis, not alkalosis.

Which nursing care would the nurse provide for an infant the first 24 hours after surgical placement of a ventriculoperitoneal shunt for hydrocephalus?

Monitoring the infant for increasing intracranial pressure Rationale: The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid and increased intracranial pressure. Although providing pain relief for the infant is an important part of postsurgical care, monitoring for potentially severe complications such as increased intracranial pressure takes precedence. Positioning the infant flat helps prevent complications that may result from a too-rapid reduction of intracranial fluid. The infant is positioned off the shunt to prevent pressure on the valve and incision area.

A client reports a loss of 20 pounds (9 kg) in 3 months and black, tarry stools. A colonoscopy is scheduled. Which instructions would the nurse give to prepare the client for this test?

The nurse tells the client not to eat or drink anything the morning of the test. Rationale: Eating or drinking the morning of the test could interfere with the test results. A liquid, not bland, diet should be consumed the night before the test. An oil-retention enema will interfere with visualization during the colonoscopy and should not be administered. Diarrhea should not occur after the test.

A pregnant client tells the nurse, "I'm sticking to my diet, and I don't eat anything containing salt." How would the nurse respond?

"Salt is necessary in your diet. Use a little when you're cooking, but avoid processed meats and canned foods with salt." Rationale: Sodium is important in the diet of a pregnant woman and so she is counseled to continue moderate sodium intake. Blood volume increases during pregnancy; sodium is required to maintain physiological edema in interstitial spaces so blood volume is not depleted. High-sodium processed meats and canned foods with added salt are discouraged in diets for all adults, not just pregnant women. Telling the client that she is doing fine is false reassurance. Salt restriction does not prevent swollen feet, other peripheral edema, or preeclampsia. Increasing salt intake during pregnancy is unnecessary, as there is enough salt in the average diet to meet the increased sodium needs of pregnant women.

After a subtotal gastrectomy, a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. Which would the nurse determine is the cause of the latter effect?

An overproduction of insulin that occurs in response to the rise in blood glucose Rationale: The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome. The physiological adaptations related to late dumping syndrome are caused by an increase in insulin, not glucose. The insulin-adjusting mechanism is not overwhelmed but responds vigorously, causing rebound hypoglycemia. Dumping syndrome is related to the high glucose content of food, not the amount of food entering the duodenum.

A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows bradycardia, and a change is seen in the contour of the client's abdomen. Which is the nurse's immediate action?

Alerting staff to the need for immediate cesarean delivery Rationale: Client history, fetal bradycardia, and change of abdominal contour indicate uterine rupture, which requires immediate cesarean delivery. Another nurse would be immediately enlisted to notify the operating room staff, primary health care provider, anesthesiologist, and neonatal team to prepare. Vital signs may be checked immediately after another nurse has been asked to bring the team together. Positioning on the left side does not address uterine rupture. Placing an internal fetal monitor is a poor use of valuable time and requires a prescription from the primary health care provider.

The nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. Which interventions would the nurse include to decrease the risk of complications? Select all that apply. One, some, or all responses may be correct

Examine the feet daily. Wear well-fitting shoes. Perform regular exercise. Rationale: Clients with diabetes often have peripheral neuropathies and are unaware of discomfort or pain in the feet; the feet should be examined every night for signs of trauma. Well-fitting shoes prevent pressure and rubbing that can cause tissue damage and the development of ulcers. Daily exercise increases the uptake of glucose by the muscles and improves insulin use. Powdering the feet after showering may cause a pastelike residue between the toes that may macerate the skin and promote bacterial and fungal growth. Generally, visiting the primary health care provider weekly is unnecessary. Clients with diabetes often have peripheral neuropathy and are unable to accurately evaluate the temperature of bathwater, which can result in burns if the water is too hot.

The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client?

Hypokalemia Rationale: In case of hypokalemia, the nurse would assess the respiratory status of the client every 2 hours. In case of hyperkalemia, the nurse would notify the health care team if the heart rate falls below 60 beats per minute or T waves become spiked. In case of hyponatremia, the nurse would be aware of muscle weakness in the client and immediately check respiratory effectiveness. In case of hypernatremia, the nurse would assess the client hourly for excessive losses of fluid, sodium, or potassium.

Which intervention would prevent urinary stasis and formation of renal calculi in an immobile client?

Increasing oral fluid intake to 2 to 3 L/day Rationale: Increasing oral fluid intake to 2 to 3 L/day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase the risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

The nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is indicative of acute pancreatitis?

Serum lipase Rationale: Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct.

Providing oxygen Assessing vital signs Obtaining a 12-lead EKG Drawing blood for cardiac enzymes Auscultating heart sounds Administering nitroglycerin Rationale: The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.

A client underwent surgery and developed a wound without tissue loss. While caring for the client, the nurse detects abscess formation. Which assessments made by the nurse support the observation? Select all that apply. One, some, or all responses may be correct.

Purulent drainage from the incision site Localized fluctuance beneath the wound when palpated Rationale: Purulent drainage from the incision site's portion is detected during checks performed every 24 hours to detect abscess formation until sutures or staples are removed. Localized fluctuance and tenderness beneath a portion of the wound is palpated to detect abscess formation. Wound dehiscence is indicated by the presence of necrosis of skin edges. Swelling of the incision line or erythema of the incision line of more than 1 cm indicates cellulitis.

Which intervention would the nurse perform first for a clinic client reporting a productive cough with copious yellow sputum, fever, and chills for the past 2 days?

Take the temperature. Rationale: Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; it is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen is needed for blood gases; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

Which information would the nurse teach to a client who has had a total simple mastectomy before the client leaves the hospital?

Why self-examination of the remaining breast is important Rationale: A person who has cancer of a breast is at risk for the development of cancer in the other breast. A breast prosthesis is not used until healing has occurred. Most clients are able to resume full activity as strength returns. Stretching activities are considered helpful in regaining full movement.

A small-for-gestational-age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. Which condition is the nurse concerned with regarding these manifestations?

Hypoglycemia Rationale: SGA infants may exhibit hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. These are not signs of hypervolemia. Hypervolemia is usually the result of excessive intravenous infusion. It is unlikely that a full-term SGA infant will need intravenous supplementation. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.

The nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. Which client statement indicates to the nurse that the teaching was effective?

"I should tell the health care provider if I'm increasing my physical activity." Rationale: Increased activity without an increase in medication can precipitate a myasthenic crisis. Self-medication with over-the-counter medications may result in medication interactions and serious consequences. A dose of pyridostigmine bromide should not be skipped because doing so may result in severe respiratory distress. People with myasthenia gravis should avoid crowds and others with colds; they are more prone to respiratory infections because of an ineffective cough and a potential for aspiration.

Which size of induration after a tuberculin test signifies a positive result in a 16-year-old client with no risk factors? Record your answer using a whole number.

15 mm Rationale: The nurse would consider an induration of 15 mm (1.5 cm) a positive sign of tuberculin testing in a 16-year-old client.

Three days after the application of a spica cast, a toddler has a temperature of 101.4°F (38.6°C). Which clinical finding would the nurse anticipate?

A foul odor from the cast Rationale: A foul smell from the cast is usually indicative of an infection under the cast that may be the cause of a fever. Respirations may increase, but do not become irregular with a fever. Itching around the top of the cast should not cause a fever; it may indicate neurovascular impairment. Tingling toes are not a sign of infection; this may indicate a neurovascular complication.

Which parent education would the parent include about cast care for an infant?

Assess the skin at the edges of the cast. Rationale: Rough cast edges can cause skin irritation and breakdown. Lotions applied to the skin at the edges of a cast can also promote skin breakdown. The skin under the cast may become macerated as a result of inadequate drying after water immersion. Adhesive petals will not adhere to a damp cast even if the cast is composed of fiberglass; it takes about a half-hour for it to dry.

Which nursing action takes priority during the admission process to the birthing unit?

Auscultating the fetal heart Rationale: Determining fetal well-being takes priority over all other measures. If the fetal heart rate is absent or persistently decelerating, immediate intervention is required. Although obtaining an obstetric history, determining when the client had her last meal, and ascertaining whether the membranes have ruptured are equally important, the determination of fetal well-being takes priority.

Which complication would the nurse be particularly alert for in a child with Reye syndrome?

Bleeding and ecchymoses from liver involvement Rationale: Reye syndrome affects the liver, causing problems with blood coagulation because liver-dependent clotting factors, such as prothrombin, are diminished. Bladder function is not impaired. Reye syndrome does not produce a rash. Reye syndrome does not involve the kidneys.

A client who had a gastric resection for cancer of the stomach is admitted to a postanesthesia care unit with a nasogastric (NG) tube in place. Which symptom would the nurse expect to observe?

Bright red, bloody drainage in the suction container Rationale: Drainage is bright red initially and gradually becomes darker red during the first 24 hours. If the nasogastric tube is functioning correctly, secretions will be removed, and vomiting will not occur. Because the bowel was emptied before surgery and the client is now nothing by mouth, intestinal activity is not expected. If the nasogastric tube is functioning correctly, gastric distention will not occur.

Which action would the nurse take when a client's membranes rupture while her labor is being augmented with an oxytocin infusion and variable decelerations in the fetal heart rate occur?

Change the client's position. Rationale: Variable decelerations are usually the result of cord compression; a change of position will relieve the pressure on the cord. Variable decelerations are not related to the mother's blood pressure or to the oxytocin. Preparing the client for an immediate birth is premature; other nursing measures should be tried first.

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. What is the primary reason for this instruction?

Decreased placental perfusion is seen in the supine position. Rationale: In the supine position the gravid uterus impedes venous return; this causes decreased cardiac output and results in reduced placental circulation. This in turn can lead to fetal compromise. Although a prolonged course of labor may result if the client lies supine, this is not the most significant reason for avoiding the supine position during labor. The supine position may result in hypotension, not hypertension. Interference with free movement of the coccyx is not the most significant reason for avoiding the supine position while in labor, although it may be partially true.

Which is the first nursing intervention for a newborn with a 1-minute Apgar score of 7?

Drying and placing the infant in a warm environment Rationale: Preventing heat loss conserves the newborn's oxygen and glycogen reserves; this is a priority. Warming the infant will reduce cyanosis if no respiratory obstruction is present. Performing a brief physical assessment is important; however, it is not a priority; assessment should be delayed until the infant is warm. Cutting the umbilical cord and attaching a clamp may be done after provisions to prevent heat loss have been made.

Which intervention would the nurse teach a client scheduled for a subtotal gastrectomy for stomach cancer to minimize postoperative dumping syndrome?

Eat 5 or 6 small meals per day Rationale: Eating smaller meals 5 to 6 times per day reduces the chance of a large amount of food emptying too quickly into the duodenum. Ambulating after meals speeds gastric emptying and should be avoided. A diet low in fat speeds gastric emptying and should be avoided. Clients should avoid increasing fluid intake when eating food, because the fluids speed gastric emptying.

Which type of biopsy is required for removal of entire lesions on the skin?

Excisional biopsy Rationale: An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

When a child is newly diagnosed with hemophilia A, the nurse will teach family members that hemophilia A is linked to a deficiency in which clotting factor?

Factor VIII Rationale: Hemophilia type A, the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and XII are part of the clotting cascade, but they are not associated with hemophilia. Factor IX is associated with hemophilia type B.

A nonstress test evaluates the condition of the fetus by comparing the fetal heart rate with which factor?

Fetal movement Rationale: In a healthy, well-oxygenated fetus the heart rate increases with fetal movement; there should be an acceleration of 15 beats with fetal movement. Fetal lie and maternal blood pressure are not a part of the evaluation of the fetus in the nonstress test. Maternal uterine contractions are used in the contraction stress test.

Which specifically would a heel stick blood test on a newborn of a diabetic mother determine?

Glucose level Rationale: Obtaining a blood glucose level is a simple, cost-effective method of testing newborns for suspected hypoglycemia. Although the acidity of the blood will indicate whether the newborn has metabolic acidosis as a result of hypoglycemia, it is more important to determine whether the newborn has hypoglycemia so it can be corrected before acidosis develops. The glucose tolerance test and glycosylated hemoglobin level test are not used in newborns.

After a difficult birth, a neonate has an Apgar score of 4 after 1 minute. Which sign met the criterion of 2 points?

Heart rate: 100 beats/min Rationale: A heart rate of 100 beats/min or more is the only criterion that rates a 2 on the Apgar score. The pale color rates a 0. A slow respiratory rate or a weak cry rates a 1. A grimace after testing of reflex irritability rates a 1.

When a client receiving hemodialysis has an external shunt for circulatory access, the nurse would be most concerned about which possible complication?

Hemorrhage Rationale: Exsanguination (hemorrhage) can occur in a matter of minutes if cannulas are dislodged. Infection, skin breakdown, and impaired circulation are not life-threatening situations; preventing hemorrhage takes priority.

How would anxiety affect outcomes for a client with heart failure?

Increases the cardiac workload Rationale: Anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increase cardiac workload and worsen outcomes in clients with heart failure. Anxiety does not directly interfere with respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen needed for body functions.

Which positioning would be avoided while assessing a client with a history of asthma?

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

Which nursing intervention would the nurse implement for a forgetful, disoriented client who has Alzheimer disease?

Managing the client's unsafe behaviors Rationale: The nurse would manage the client's unsafe behaviors. Clients with Alzheimer disease require external controls to minimize the danger of injury caused by lack of judgment. The staff would not prevent gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration cannot be prevented in this disorder. It is not recommended to continually orient a client with Alzheimer disease; this can increase agitation.

The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of concern to the nurse?

Spontaneous rupture of membranes 3 hours ago Rationale: Rupture of the membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus. GBS infection is a leading cause of neonatal morbidity and mortality. Continued bloody show, cervical dilation of 4 cm, and contractions every 4 minutes are all normal findings for a client in labor.

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated with this result?

Neural tube defect Rationale: Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

A client's laboratory report indicates a client's aldolase (ALD) is 9 units/dL. Which diseases may occur in the client with this laboratory report? Select all that apply. One, some, or all responses may be correct.

Polymyositis Dermatomyositis Muscular dystrophy Rationale: Polymyositis, dermatomyositis, and muscular dystrophy may occur due to the elevated levels of ALD. Note that the normal ALD levels range from 3 to 8.2 units/dL. Osteoporosis may occur due to elevated serum calcium. Muscle trauma may occur due to high levels of serum creatinine kinase (CK). Metastatic cancers of the bone may occur due to high levels of alkaline phosphatase.

After a subtotal gastrectomy, a client is returned to the surgical unit. Which is an appropriate nursing action to prevent pulmonary complications?

Promoting frequent turning and deep breathing to mobilize secretions Rationale: To promote drainage of different lung regions, clients should turn every 2 hours. Deep breathing inflates the alveoli and promotes fluid drainage. During physical effort, individuals with abdominal incisions often revert to shallow breathing. Oxygen administration is a dependent function and generally is not required unless there is underlying cardiac or respiratory disease. There is no indication that a nonrebreather mask is needed.

A child has partial-thickness burns of the face and upper chest. Which is the priority nursing assessment for the first 24 hours?

Pulmonary distress Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs. Although wound sepsis is a possible complication, it will not be evident until the third to fifth day. Although the child is probably fearful, maintaining a patent airway is the priority. This child is too old for separation anxiety; however, complications related to stress may occur later. Fluid losses may be extremely high but reach their maximum about the fourth day; the initial priority is maintaining a patent airway.

Which area of assessment is included in the Glasgow Coma Scale?

Response to verbal commands Rationale: The three areas of assessment to determine the level of consciousness using the Glasgow Coma Scale are motor response to verbal commands, eye opening in response to speech, and verbal response to speech. Assessing breathing patterns, deep tendon reflexes, and eye accommodation are not included in the Glasgow Coma Scale.

When a client with chest pain is having an exercise electrocardiogram (ECG), which finding by the nurse would require the most rapid action?

ST-segment depression Rationale: ST-segment depression is an indication of myocardial ischemia and the nurse would have the client stop exercising and would continue to monitor the ECG and blood pressure. Heart rate normally increases with exercise. Blood pressure also normally increases with exercise. Shortness of breath is normal with stress testing because the client is running on a treadmill.

A client with a ruptured appendix is scheduled for an appendectomy. Preoperatively, the nurse would place the client in which position?

Semi-Fowler Rationale: The semi-Fowler position localizes the spilled contents of the ruptured appendix in the lower part of the abdominal cavity. The Sims and left-lateral positions allow the contents of the bowel exiting the ruptured appendix to disperse throughout the abdominal cavity; also, they exert pressure on the abdomen, which may be uncomfortable for the client. The dorsal recumbent position will not localize spilled intestinal contents in the lower part of the abdomen.

Which action would be appropriate to implement when collecting a 24-hour urine test?

Start the time of the test after discarding the first voiding. Rationale: The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour period for the test is not necessary; voided specimens are acceptable. Inserting a urinary retention catheter is not a standard step. Straining the urine after each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

Which observation would prompt the nurse to further assess the interaction between a mother and her 9-month-old infant?

The mother speaks in baby talk. Rationale: Language patterns and sounds are established in the first year of life. Because speech is a learned skill, parents should talk to their infants in a natural voice and avoid baby talk to reduce the risk of language development problems. Stranger anxiety peaks at 9 months, and object permanence is not fully developed; therefore the infant can be expected to be upset when the mother leaves the child with the nurse. At 9 to 10 months the infant may use sounds to refer to objects; a child may not say his or her first words until 10 to 13 months of age. Dropping food, toys, or other objects when someone is there to pick them up is part of the learning process of object permanence.

Which statements correctly states how toddlers are different from infants?

Toddlers grow at a slower rate. Rationale: The growth rate of toddlers is slower than that of infants. The incidence of lead poisoning is highest in both late infancy and toddlerhood. Toddlers have accentuated cervical and lumbar vertebral curves, whereas infants lack them. URTIs are usually not dangerous, and infants and toddlers both recover from them with little difficulty.

Which results would be expected when assessing the laboratory values of a client with type 2 diabetes?

Urine negative for ketones and positive glucose in the blood Rationale: The reason for the lack of ketonuria in type 2 diabetes is unknown. One theory is that extremely high hyperglycemia and hyperosmolarity levels block the formation of ketones, stimulating lipogenesis rather than lipolysis. Ketones in the blood but not in the urine do not occur with type 2 diabetes. Glucose in the urine but not in the blood is impossible; if glycosuria is present, there must first be a level of glucose in the blood exceeding the renal threshold of 160 to 180 mg/dL (8.9−10 mmol/L). Urine and blood positive for glucose and ketones are expected in type 1 diabetes.

The nurse would notify the health care provider with which finding in a child being observed following a closed head injury?

Vomiting Rationale: Vomiting is a sign of increased intracranial pressure. This finding would cause the nurse to notify the health care provider. Normal pupil size ranges from 2.0 to 5.0 mm. The expected respiratory rate for a school-aged child is 20 to 30 breaths/min. The systolic blood pressure range for a school-aged child is 80 to 120 mm Hg. These are all expected findings and are not cause for concern on the part of the nurse.

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, which information about the client would the nurse obtain?

Whether the result of an earlier tuberculin test was positive Rationale: A tuberculin test should not be administered to a client with a previous positive result on a tuberculin test because a severe reaction may occur at the test site in a previously sensitized individual. It is more important to know whether the test result was positive than whether a test was performed. Being prone to respiratory diseases is not a contraindication to having a tuberculin test unless the client is infected with tuberculosis. Although a family history may have involved exposure of the client to tuberculosis, the client may not have had a positive tuberculin test result; also, many years may have elapsed since the exposure.

When a client is using a hypothermia blanket to reduce fever, which finding indicates a need for a change in the treatment?

Shivering Rationale: Shivering should be prevented because peripheral vasoconstriction increases temperature, circulatory rate, and oxygen consumption. Hypothermia therapy does not cause vomiting, and vomiting is not an indication of a need to modify hypothermia. Dehydration is not a response to hypothermia therapy, although fever can cause dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance. Hypotension is not a response to hypothermia therapy, although hypotension can occur with dehydration if oral or parenteral fluid intake is inadequate to maintain fluid balance.

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding?

"I should apply powders or talc on a perineum wound." Rationale: A client should not use powders or talc on the perineum wound, and the nurse needs to follow up to correct this misconception. All the other statements are correct and need no follow-up intervention. The client should gently pat the skin rather than rub. The client should use mild, heavily fatted soap. The client should use tepid rather than hot water.

A registered nurse teaches a nursing student about routines followed during a physical examination to help ensure that important findings are not missed. Which statement by the nursing student is incorrect?

"I'll perform painful procedures at the beginning of the examination." Rationale: Any painful procedures should be performed at the end of the examination. The two sides of the body should be compared for symmetry, because some asymmetries are abnormal. Recording quick notes during the examination will help prevent delays during the examination. More extensive notes may be completed at the end of the examination. Assessments should be recorded in specific terms in the electronic or paper record. This standard form allows information to be recorded in the same sequence in which it is gathered.

A 28-year-old woman who has phenylketonuria (PKU) tells the nurse she wants to become pregnant and that she consumed a low-phenylalanine diet until she was 18 years old. Which response would the nurse provide?

"Return to the low-phenylalanine diet before becoming pregnant." Rationale: It is essential that a woman with PKU return to a low-phenylalanine diet before becoming pregnant; phenylalanine crosses the placenta, and a high blood level can damage the fetus, especially during organogenesis. Consuming a regular pregnancy diet can endanger the fetus. Starting the low-phenylalanine diet in the third trimester is too late to protect the fetus. Advising a client to consume a low-protein diet is too vague and starting the diet in the second trimester is too late to protect the fetus.

A client with end-stage renal disease (ESRD) received a kidney transplant and is transferred to the postanesthesia care unit. At which frequency would the nurse assess the client's urinary output?

1 hour Rationale: Hourly output is critical in assessing kidney function; decreasing urinary output is a sign of rejection. Every 2 hours is too infrequent for monitoring output immediately after a kidney transplant; the priority is to monitor output more frequently to evaluate function of the new kidney. Monitoring the urine output every 15 or 30 minutes is not necessary.

An adolescent wants to have bariatric surgery. Which are the criteria for this surgery? Select all that apply. One, some, or all responses may be correct.

Adherence to nutritional guidelines after surgery BMI of at least 40 with severe obesity Ability to give informed consent to surgery Rationale: Bariatric surgery is performed on clients with morbid obesity. Adolescents after surgery should strictly adhere to the nutritional guidelines. A body mass index of at least 40 with severe obesity and other health problems is a criterion to have bariatric surgery. The adolescent should agree to avoid pregnancy for 1 year postoperatively. The adolescent should give informed consent to the surgery. Regular exercise is needed to stay healthy but is not a criterion.

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client reports the need to urinate. What would the nurse do first?

Assess that the tubing attached to the collection bag is patent. Rationale: The drainage tubing may be obstructed. Retained fluid raises bladder pressure, causing discomfort similar to the urge to void. The client's vital signs are not related to the complaint, but will be assessed often in the postoperative period. Although the nurse may review the client's intake and output, it is not the priority. Whether urine is draining from the tubing at this point in time is significant. Although it is true that the balloon inflated in the bladder causes this feeling, the patency of the gravity system should be ascertained before determining the cause of the complaint.

An infant has had a pyloromyotomy performed after the diagnosis of hypertrophic pyloric stenosis. In which position would the nurse teach the mother to place the infant during and after feeding?

At a 90-degree angle for feedings; on the right side with the upper body elevated afterward Rationale: During and after feeding, the position that most favors gravity is used to promote retention of fluid, prevent vomiting, and facilitate flow of gastric contents through the pyloric sphincter; therefore the infant should be placed at a 90-degree angle on the right side with the upper body elevated. Feeding any child in the supine position increases the risk for aspiration. Vomiting may continue after surgery; there should be limited movement after feedings. With the infant in an elevated, not side-lying, position, gravity facilitates retention of the feeding. Although postoperative positioning with the head elevated aids retention of feedings, the prone position is avoided to prevent vomiting and aspiration, as well as sudden infant death syndrome.

An adolescent child who has sustained full-thickness burns is to undergo skin grafting. Which treatment is permanent?

Autografts Rationale: Autografts consist of tissue from the individual's own body, meaning that the chance of rejection is minimal. Steroids are not part of the therapy for skin grafts. Homografts consist of tissue from genetically different members of the same species, usually a cadaver; they are used as temporary grafts. Immunosuppressive medications are not part of the therapy for skin grafts.

Which radiographic test is used to view the entire skeleton?

Bone scan Rationale: A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.

Which action would the nurse plan for a client during the early postoperative period after a prostatectomy?

Discourage straining for a bowel movement. Rationale: Straining applies pressure to the operative site, which can precipitate bleeding and should be avoided. A retention catheter is routinely put into place, so standing to void and not voiding by bedtime are not applicable. To prevent trauma, negative pressure should not be exerted on the bladder by using a bulb syringe to aspirate.

When arterial blood gas results for an alert client who is in the postanesthesia care unit (PACU) after abdominal surgery are pH 7.37, PaCO 2 42 mm Hg (5.59 kPa), HCO 3 25 mEq (25 mmol/L), PaO 2 65 mm Hg (8.64 kPa), and SaO 2 90% (0.90), which action would the nurse take?

Increase the oxygen flow rate. Rationale: Because the arterial blood gases indicate mild hypoxemia and normal acid-base balance, the nurse would increase the oxygen flow rate. Insertion of an oropharyngeal airway is unnecessary and contraindicated in an alert client because it will activate the gag reflex. There is no indication that the client needs suctioning. Because the client is hypoxemic, further monitoring and anesthesia recovery are needed before transferring from the PACU.

The nurse is caring for a client who has had surgery for cancer of the pancreas. The postoperative plan of care will include limiting which type of dietary intake?

Fats and carbohydrates Rationale: Fats and carbohydrates should be limited because the exocrine function of the pancreas is the formation of lipase for fat digestion, and the endocrine function of the pancreas is the secretion of insulin, a hormone that is essential for carbohydrate metabolism. Proteins and grains, as well as vitamins and minerals, are not as severely affected as fats and carbohydrates, especially glucose. Deficiencies of protein may occur because of inadequate intake but are not related specifically to pancreatic functioning. Beef and chicken are protein, which is not as affected as fats and carbohydrates.

For which acute, life-threatening complication would the nurse monitor during the client's early postoperative period after a radical nephrectomy?

Hemorrhage Rationale: The kidney, an extremely vascular organ, receives a large percentage of the blood flow. Hemorrhage from the operative site is a potential complication. Sepsis and renal failure may occur later in the postoperative period. Paralytic ileus can occur, but it is not life threatening.

A client is receiving hemodialysis for chronic kidney disease. For which complication would the nurse monitor the client?

Hepatitis B Rationale: Hepatitis type B is transmitted by blood or blood products. The hemodialysis and routine transfusions needed for a client in end-stage renal failure constitute a high risk for exposure. Peritonitis is a danger for individuals receiving peritoneal dialysis. Renal calculi are not a complication of hemodialysis; they often occur in clients who are confined to prolonged bed rest. Dialysis does not involve the bladder and will not contribute to the development of a bladder infection.

A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. Which cerebrospinal fluid (CSF) laboratory finding would support this diagnosis?

Increased protein level The blood-brain barrier is affected in bacterial meningitis, permitting the passage of protein into the cerebrospinal fluid (CSF). The cell count will be increased. The glucose level is decreased in proportion to the duration of the disease. Spinal fluid pressure will be increased.

The nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, which nursing intervention is required?

Maternal rubella vaccination Rationale: A rubella immunity result stating not demonstrated would indicate the need for rubella immunization, and immediately postpartum is an ideal time to administer the vaccine. Rubella immunization protects the fetuses of future pregnancies from significant birth defects that could be caused by a rubella infection. The Hgb (hemoglobin) and Hct (hematocrit) results are borderline for pregnancy but were taken during the prenatal period and do not represent the woman's current status. There is no evidence that the neonate needs a transfusion. A RhoGAM injection is not needed because both the infant and the mother are Rh negative. A glucose level of 46 is acceptable for a neonate.

Which findings for a client who has a cast applied to the lower extremity indicate a complication? Select all that apply. One, some, or all responses may be correct.

Numbness Prolonged capillary refill Rationale: Numbness is a neurological sign that should be reported immediately, because it indicates pressure on the nerves and blood vessels. Compression of arterial vessels results in a prolonged return of blood to the periphery after compression of capillaries and is indicative of compromised circulation. Warmth is an expected reaction to a new cast. Desquamation becomes apparent after a cast is removed. Some degree of discomfort is expected after cast application.

Within the first 2 hours after a radical neck dissection, a large amount of bloody fluid is collected in the portable wound drainage system. Which action would the nurse take first?

Obtain the client's vital signs. Rationale: The nurse's first action after noting a large amount of postoperative bleeding would be to check the vital signs to monitor for tachycardia or hypotension. Vital signs would be obtained before talking with the health care provider, because the health care provider would need to know the client's status. Documentation of the drainage is needed, but it can be done after the provider has been notified and any new actions taken. The nurse will continue to monitor drainage, but monitoring alone would be unsafe in a client with active bleeding.

Which finding would the nurse expect in the urinalysis report of a client with diabetes insipidus?

Specific gravity of urine: 0.4 Rationale: The normal specific gravity of urine lies between 1.003 and 1.030. The specific gravity of urine of clients with diabetes insipidus is low due to the impaired functioning of antidiuretic hormone. The pH of normal urine ranges from 6.5 to 7.0. A pH higher than 8 indicates a urinary tract infection (UTI). Normal urine contains between 0 and 4 hpf of RBCs. A count greater than 4 hpf indicates tuberculosis, cystitis, neoplasm, and glomerulonephritis. In a normal urine sample, WBCs lie in the range of 0 to 5 hpf. Any increase in the number of WBCs indicates a urinary tract inflammation.

A child arrives at the emergency department after hitting his head and falling from his treehouse. He now complains of a headache and feels sick to his stomach. Which activity would the nurse have the child do to assess his motor responses?

Squeezing the nurse's hand Rationale: Motor responses are tested by assessing the strength of the hand grasps, movement, and strength of the upper and lower extremities. Drawing is used to assess hand-eye coordination. Balancing on one foot is part of the Romberg test; it is used to evaluate cerebellar integrity. Gait and posture are also indicators of cerebellar integrity.

Which finding indicates that a client's kidney transplant is successful?

Decreasing serum creatinine Rationale: As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. With end-stage renal disease, fluid retention causes hypertension; there should be a correction of hypertension, not hypotension. After the transplant, the serum potassium should correct to within expected limits for an adult.

Which clinical finding would prompt the nurse to perform further assessment of an infant with Down syndrome?

Circumoral cyanosis Rationale: Circumoral cyanosis is not a specific characteristic of Down syndrome. It is a clinical finding associated with congenital heart disease, which may co-occur in a child with Down syndrome. A flat occiput and a broad nose with a depressed bridge (saddle nose) are features of children with Down syndrome. Small, misshapen, low-set ears are also a clinical manifestation of Down syndrome. Children with Down syndrome often keep their mouths open, with their tongues protruding; the surface of the tongue is often wrinkled.

The nurse is caring for a new mother who has a chlamydial infection. For which complications would the nurse assess the client's neonate? Select all that apply. One, some, or all responses may be correct.

Pneumonia Preterm birth Conjunctivitis Rationale: Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy.

The parents of a 4-year-old child call and report that their child has a fever of 102.6°F (39.2°C), is complaining of a sore throat, and will not lie down, preferring to sit up and lean forward. The child is drooling and looks ill and agitated. Which guidance would the nurse provide this family?

The child needs immediate medical attention; call 911. Rationale: This child is presenting with signs and symptoms of epiglottitis, which is a medical emergency because of airway obstruction. Cool mist is effective in reducing the inflammation of croup, but it usually is not effective in epiglottitis; the child will not be able to drink any fluids because of the enlarged epiglottis. A nonsteroidal anti-inflammatory medication such as ibuprofen may help reduce fever, but the child will have difficulty swallowing, which may cause the epiglottis to spasm and close off the airway. Waiting to call is unsafe.

A client is diagnosed with pheochromocytoma. Which finding in the urinalysis report supports the diagnosis?

Total catecholamines: 640 mmol/24 h Rationale: Total catecholamines increase as a result of pheochromocytoma, stress, neuroblastoma, and heavy exercise. A total catecholamine level below 591 mmol/24 h is normal. The client's report shows 640 mmol/24 h of total catecholamines, which is higher than the normal range. The total catecholamine levels in the client's urinalysis report suggest pheochromocytoma. Sodium concentrations in the range of 40 to 220 mmol/24 h are normal. The client has a sodium concentration of 200 mmol/24 h, which is a normal finding. The normal levels of calcium in the urine range between 2.5 and 7.5 mmol/24 h. The client has a calcium concentration of 5.6 mmol/24 h, which is a normal value. The normal values of urea nitrogen range from 0.43 to 0.71 mmol/24 h. The client has a urea nitrogen level of 0.5 mmol/24 h, which is a normal finding.