NCLEX A1
A client was diagnosed with having right subarachnoid hemorrhage. The nurse should plan to place the client in which position? with the head of the bed elevated on the right side on the left side flat in bed
with the head of the bed elevated Explanation: Elevating the head of the bed enhances cerebral venous return and thereby decreases intracranial pressure (ICP). The other positions wouldn't decrease ICP. Remediation: Subarachnoid hemorrhage
A client with peptic ulcer disease is receiving propantheline bromide. Which finding indicates to the nurse that the medication has been effective? subsiding of nausea and vomiting decreased abdominal bloating reduced abdominal pain normal temperature
reduced abdominal pain Explanation: Propantheline bromide is given to a client with peptic ulcer because it inhibits gastrointestinal motility and decreases gastric acid secretion. This reduces the pain caused by excessive acid production with peptic ulcers. The drug does not have an antiemetic effect, nor does it reduce abdominal bloating or reduce fever caused by infection. Remediation: Cholelithiasis, cholecystitis, and related disorders
A client with muscle weakness and an abnormal gait is being evaluated for muscular dystrophy. Which of the following confirms muscular dystrophy? Electromyography Muscle biopsy Family history of muscular dystrophy Gram stain of muscle tissue
Muscle biopsy Explanation: A muscle biopsy showing fat and connective tissue deposits confirms the diagnosis of muscular dystrophy. Electromyography commonly shows short, weak bursts of electrical activity in affected muscles; however, it isn't a conclusive test for muscular dystrophy. A family history of muscular dystrophy only suggests the disorder. A Gram stain of muscle tissue is inconclusive. Remediation:Muscular dystrophy
An older adult client with heart failure and 2+ pitting edema is prescribed furosemide. Due to the effects of furosemide, which supplemental medication would the nurse expect to see ordered for this client? diflucan digoxin potassium sodium bicarbonate
potassium Explanation: Supplemental potassium is given with furosemide because of the potassium loss that occurs as a result of this diuretic. Sodium is not lost during diuresis. Digoxin acts to increase contractility, but it isn't given routinely with furosemide. Diflucan is an antifungal and is not given routinely with furosemide. Remediation: furosemide
A nurse is preparing to perform an abdominal assessment. Which sequence would the nurse follow to effectively perform an abdominal examination on a client? Inspection, auscultation, percussion, and palpation Inspection, auscultation, palpation, and percussion Inspection, percussion, palpation, and auscultation Inspection, palpation, percussion, and auscultation
Inspection, auscultation, percussion, and palpation Explanation: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation. Remediation: Assessment techniques
A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time? Instituting droplet precautions Administering acetaminophen Obtaining history information from the parents Orienting the parents to the pediatric unit
Instituting droplet precautions Explanation: Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority. Remediation: Droplet precautions Meningitis, pediatric
The nurse is preparing the room for a client diagnosed with varicella. Which sign would the nurse place on the room door?
airborne precaution Explanation: In addition to contact precautions, the nurse would place the client diagnosed with varicella in airborne precautions. Airborne precautions include a face mask for the client/respirator for the nurse and personal protective equipment including gown and gloves. Droplet precautions are indicated for viruses, B. ordetella pertussis, and group A streptococcus. Contact precautions are indicated anytime a nurse may come in contact with any body fluids.
A client is in the last trimester of pregnancy. The nurse should instruct her to notify her obstetrician immediately if she notices: blurred vision. hemorrhoids. increased vaginal mucus. dyspnea on exertion.
blurred vision. Explanation: Blurred vision or other visual disturbances, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for the client and fetus. Although hemorrhoids may be a problem during pregnancy, they don't require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.
The nurse has been working with a client who has abused alcohol for the last 72 hours. What symptoms does the nurse identify as being related to alcohol withdrawal? diaphoresis, tremors, bradycardia, and hypertension diaphoresis, tremors, bradycardia, and hypotension diaphoresis, tremors, tachycardia, and hypertension diaphoresis, tremors, tachycardia, and hypotension
diaphoresis, tremors, tachycardia, and hypertension Explanation: Delirium tremens is characterized by increased blood pressure, pulse, and respirations, and an increase in psychomotor activity. Signs/symptoms do not include hypotension or bradycardia. Remediation: Delirium
The nurse administers sublingual nitroglycerin to a client who reports chest pain. Which client symptom should the nurse report immediately? irregular heart beat throbbing headache dizziness when standing burning under the tongue
irregular heart beat Explanation: An irregular heartbeat is a serious adverse side effect of nitroglycerine therapy and should be reported to the primary care provider. Headache, dizziness, and a burning sensation under the tongue commonly occur at the beginning of nitroglycerin therapy; however, clients typically develop a tolerance to the drug as therapy continues. Remediation: nitroglycerin (glyceryl trinitrate) Chest pain
A client with a history of heart disease is given a prescription for 4 grains of aspirin which comes in 81 mg per tablet. The client asks the nurse, "how many tablets should I take?" What is the nurse's best response? Record your answer using a whole number.
3 Explanation: I grain = 60 - 65mg. 4 grains = 240 -260mg. Therefore, 3 tablets will be needed. 240/81 - 2.962 rounded up to 3. 260/81 = 3.20 rounded to 3.
A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider? rheumatoid factor blood culture alkaline phosphatase ESR
blood culture Explanation: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture should be reported immediately to the health care provider so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L is within the normal range, and an ESR of 10 mm/hour is also within the normal range. Remediation: Osteomyelitis
The nurse is caring for a client with Cushing syndrome. The client is upset about the physical appearance and body changes that have occurred because of the syndrome. What is the nurse's best response? "As the syndrome is treated, the physical changes will go away." "Unfortunately, you cannot control the signs and symptoms." "Perhaps you need to talk to someone about your concerns." "I know how you must be feeling about the changes."
"As the syndrome is treated, the physical changes will go away." Explanation: With treatment, physical changes will eventually disappear. Telling the client they cannot control the signs and symptoms is not a helpful response. The client is sharing feelings with the nurse; it is important not to dismiss the client, and no one can know how another person feels. Remediation: Cushing syndrom
A nurse is preparing to administer oral doxycycline to a client. What is the nurse's appropriate action? Administer with food. Administer with milk. Administer with full glass of water. Administer with an antacid.
Administer with full glass of water. Explanation: Doxycycline should be given with a full glass of water on an empty stomach. It should not be taken with milk or within 2 hours of antacid administration. Remediation: doxycycline
The nurse is reinforcing education with an adolescent about metronidazole for the treatment of trichomoniasis. Which statement is important for the nurse to include in discharge education? Sexual intercourse should stop. Alcohol should not be consumed. Milk products should be avoided. Exposure to sunlight should be limited.
Alcohol should not be consumed. Explanation: While taking metronidazole to treat trichomoniasis, adolescents should not consume alcohol for at least 3 days following the last dose, because the drug is similar to disulfiram and may lead to a psychotic reaction. Milk and sunlight have no effect on the adolescent while taking this medication. Sexual intercourse need not be avoided.
A client comes to the emergency department reporting dull, deep bone pain unrelated to movement. Which statement is correct to determine if the bone pain is caused by a fracture? These are classic symptoms of a fracture. Fracture pain is sharp and related to movement. Fracture pain is sharp and unrelated to movement. Fracture pain is dull and deep and related to movement.
Fracture pain is sharp and related to movement. Explanation: Fracture pain is sharp and related to movement. Pain that's dull and deep and unrelated to movement isn't typical of a fracture. Remediation: Fracture (arm or leg)
A toddler is brought to the emergency department in cardiac arrest. The physician tries three times to insert an I.V. catheter but is unsuccessful. By which alternate route can the physician administer emergency medications? Sublingually Topically Subcutaneously Intraosseously
Intraosseously Explanation: The physician can safely administer emergency medications, such as sodium bicarbonate, calcium, glucose, crystalloids, colloids, blood, dopamine, epinephrine, and dobutamine by the intraosseous route if the I.V. route is inaccessible. Emergency medications shouldn't be administered by the sublingual, topical, or subcutaneous routes. Remediation: Intraosseous infusion device insertion, assisting, pediatric
A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? Obtain vital signs. Document history of the symptoms. Assess bowel sounds and abdominal tenderness. Insert an NG tube and connect to suction.
Obtain vital signs. Explanation: The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority, and a health care provider's order is needed for an NG tube placement.
A client has been admitted with scabies. Which graphic depicts this skin disorder?
The third graphic (C) correctly depicts scabies in a straight or zigzagging line with a black dot at the end. The first graphic (A) depicts herpes zoster, which appears as a group of vesicles or crusted lesions along a nerve root. The second graphic (B) depicts tinea corporis (ringworm), which is characterized by round, red, scaly lesions that are accompanied by intense itching. The fourth graphic (D) depicts psoriasis, which is characterized by symmetrical plaques and appears with a red base and silvery scales.
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 1 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? Vesicles Bullae Cysts Pustules
Vesicles Explanation: Vesicles are elevated, sharply defined lesions, usually less than 1 cm in diameter, that contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 1 cm in diameter; an example is a second-degree burn wound. Cysts are elevated, thick-walled lesions containing fluid or semisolid matter; they include sebaceous cysts. Pustules are elevated lesions less than 1 cm containing purulent material; examples include impetigo and acne lesions. Remediation: Skin assessment, long-term care
An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by: cerebral bleeding. I.M. injection. myocardial necrosis. skeletal muscle damage due to a recent fall.
myocardial necrosis. Explanation: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can be caused by I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery. Remediation: Myocardial infarction
A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations of all procedures and medications. The nurse identifies which assessment as evidence that the client has achieved an increased level of psychological comfort? making decreased eye contact asking to see family members joking about the present condition sleeping undisturbed for three hours
sleeping undisturbed for three hours Explanation: Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions. Remediation: Relaxation and stress management techniques
The nurse is completing the admission assessment of a client in the labor and delivery area, when the client and her husband ask whether their sons, ages 8 and 10, can witness the childbirth. Which statement made by the nurse is accurate? "The children and client should share a support person during the childbirth." "Children should attend childbirth only if it takes place at home." "Children shouldn't attend childbirth because it will frighten them." "Each child attending the childbirth should have a separate support person."
"Each child attending the childbirth should have a separate support person." Explanation: Each child attending the childbirth should have a support person — one who isn't also serving as the client's support person. The support person explains what is happening, reassures the child, and removes the child from the area if an emergency occurs or if the child becomes frightened. Children can attend childbirth in any setting. The decision to have a child present hinges on the child's developmental level, ability to understand the experience, and amount of preparation.
24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse? "It's important to observe these types of behaviors and make necessary referrals to the social worker." "Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience." "Make sure you don't assume the care for the baby. Encourage the mother to change change diapers and take responsibility for feeding." "It's sad that some women don't seem to appreciate the gift of a healthy baby."
"Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience." Explanation: Postpartum fatigue is common and many clients go home with a sleep deficit. A multigravida client has already experienced the challenges of sleep deprivation with a newborn and understands the need to recuperate. In Rubin's taking-in phase, the mother is commonly focused on her own needs and is only passively involved with the infant for 1 to 2 days postpartum. As the mother integrates her birth experience, she'll start the taking-hold phase and will increasingly shift her attention to the infant. Referral to a social worker is premature at this time. Although nurses need to allow mothers to care for their infants as much as possible, rest for the mother is also important.
During her first prenatal visit, a client expresses concern about gaining weight. Which action should be the nurse's next step? Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. Be alert for a possible eating problem and do a further in-depth assessment. Report the client's concerns to her health care provider. Ask her to come back to the clinic every 2 weeks for a weight check.
Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet. Explanation: Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy; then she can assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary. Remediation: Developmental tasks of pregnancy: 1st trimester, accepting the pregnancy
Family members of a client report to the nurse that they are exhausted and it is difficult taking care of a dependent family member. Which approach by the nurse is in the client's best interest? 1 Ask the client what he or she would like to do. 2 Tell the family members to discuss it among themselves. 3 Tell the family the client should go to a nursing care facility. 4 Call a family conference and ask social services for assistance.
Call a family conference and ask social services for assistance. Explanation: A family conference with social services can enlighten the family to all prospects of care available to them. The client should supply input if he or she can, but this may not help solve the problems of exhaustion and care difficulties. The family may not be aware of alternative care measures for the client, so a discussion among themselves may not be helpful. The client may not qualify for a nursing care facility because of the need to meet stringent criteria.
A 2-year-old child is found on the floor next to a toy chest. After first determining unresponsiveness and calling for help, which step should be taken next? Start mouth-to-mouth resuscitation. Begin chest compressions. Check for a pulse. Open the airway.
Check for a pulse. Explanation: According to the 2015 American Heart Association (Heart and Stroke Foundation of Canadian) CPR guidelines, the sequence is C-A-B (chest compressions-airway-breathing). Initially check the child for a pulse. If no pulse is detected, perform chest compressions (30 as a single rescuer). Next, open the airway by using the head-tilt, chin-lift maneuver and, if a single rescuer, give two rescue breaths. Remediation: Cardiopulmonary resuscitation (CPR), one-person, child
The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety? 1 Identifying and confronting suspicious-looking visitors 2 Encouraging the parents to room-in with the infant 3 Keeping security cameras and alarms activated at all times 4 Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
Instructing the mother to notify staff when she showers to avoid leaving the infant unattended Explanation: Parents should be instructed to avoid leaving the infant unattended in the hospital, even while simply showering. Confronting suspicious visitors is dangerous. Suspicious visitors should instead be reported to hospital security. Rooming-in promotes bonding but doesn't ensure infant safety. Infant abductions can occur despite locked units and security equipment.
The nurse is teaching a client how to take nitroglycerin to treat angina pectoris. The client verbalizes an understanding of the need to take up to three sublingual nitroglycerin tablets at 5-minute intervals, if necessary, and to notify the physician immediately if chest pain doesn't subside within 15 minutes. The nurse informs the client that nitroglycerin may cause: nausea, vomiting, depression, fatigue, and impotence. sedation, nausea, vomiting, constipation, and respiratory depression. headache, hypotension, dizziness, and flushing. flushing, dizziness, headache, and pedal edema.
headache, hypotension, dizziness, and flushing. Explanation: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a beta-adrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic used to relieve pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.
A nurse is caring for a client who is admitted to the hospital with a bowel obstruction. Which nursing action requires the use of sterile gloves? inserting a urinary catheter performing oral suctioning changing an oxygen system drawing blood for laboratory testing
inserting a urinary catheter Explanation: Inserting an indwelling urinary catheter is the only sterile procedure listed here. Gloves are not necessary when changing an oxygen system. The nurse should wear nonsterile gloves when drawing blood and performing oral suctioning. Remediation: Indwelling urinary catheter (Foley) insertion, female Indwelling urinary catheter (Foley) insertion, male
A child with Reye syndrome is exhibiting signs of increased intracranial pressure (ICP). Which nursing intervention would be most appropriate for this child? position the child with the head elevated and the neck in a neutral position maintain the child in the prone position cluster together interventions that may be perceived as noxious position the child in the supine position, with head turned to the side
position the child with the head elevated and the neck in a neutral position Explanation: Positioning the child with Reye syndrome with the head elevated and the neck in neutral position helps decrease ICP. The prone and supine positions cause increased ICP. Interventions that may be perceived as noxious should be spaced over time because if clustered together they may have a cumulative effect in increasing ICP. Turning the head to the side may impede venous return from the head and increase ICP. Remediation: Reye syndrome, pediatric
A client with antisocial personality disorder is trying to manipulate the health care team. Which strategy is most important for the staff to use? 1 focus on how to educate the client more effectively on behaviors for meeting basic needs 2 help the client verbalize underlying feelings of hopelessness and learn coping skills 3 remain calm and don't respond emotionally to the client's manipulative actions 4 help the client eliminate the intense desire to have everything in life turn out perfectly
remain calm and don't respond emotionally to the client's manipulative actions Explanation: The best strategy to use with a client trying to manipulate staff is to stay calm and refrain from responding emotionally. Negative reinforcement of inappropriate behavior increases the chance it will be repeated. Later, it may be possible to address how to meet the client's basic needs. Clients with antisocial personality disorder don't tend to experience feelings of hopelessness or the desire for life events to turn out perfectly. In most cases, these clients negate responsibility for their behavior. Remediation: Antisocial personality disorder
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of hepatitis B who is jaundiced and reports weakness. Which intervention should the nurse include in the client's care plan? rest periods after small, frequent meals low-protein diet menus selected by the client regular exercise
rest periods after small, frequent meals Explanation: Rest periods and small, frequent meals are necessary for clients suspected of having hepatitis B and complaining of weakness. A diet high in protein is recommended to enhance the recovery of injured liver cells. The client is likely to need some guidance in menu selection. Choices can be made from high-protein foods. Regular exercise is too draining for a client with hepatitis B. Remediation: Hepatitis (viral) Jaundice
A client is diagnosed with a fat emboli. Which signs and symptoms would the nurse expect to find when gathering data from this client? tachypnea, tachycardia, shortness of breath, paresthesia paresthesia, bradypnea, bradycardia, petechial rash on chest and neck bradypnea, bradycardia, shortness of breath, petechial rash on chest and neck tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck
tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck Explanation: Signs and symptoms of fat emboli include tachypnea, tachycardia, shortness of breath, and a petechial rash on the chest and neck. The fat molecules enter the venous circulation and travel to the lung, obstructing pulmonary circulation. Bradycardia, bradypnea, and paresthesia aren't usual symptoms. Remediation: Fat embolism syndrome
A client is receiving phenytoin. Which response by a client best indicates an understanding of the adverse effects of the medication? "I should take the medication without food." "I can stop this medication if seizures stop." "I need to see the dentist every 6 months." "I should report drowsiness immediately."
"I need to see the dentist every 6 months." Explanation: Phenytoin can cause hypertrophy of the gums and gingivitis; therefore, regular dental checkups are essential. Phenytoin needs to be taken with food or after meals to decrease adverse GI reactions and should never be discontinued unless ordered by the health care provider. Some drowsiness is expected initially; however, this usually decreases with continued use. Remediation: phenytoin
A client comes to the clinic for diagnostic allergy testing. The client asks why is an intradermal injection used for this testing. How would the nurse best respond? "An intradermal injection is less painful." "Intradermal drugs are easier to administer." "Intradermal drugs diffuse rapidly." "Intradermal drugs diffuse slowly."
"Intradermal drugs diffuse slowly." Explanation: Drugs administered intradermally (injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapid introduction of an allergen into a sensitive client could cause a life-threatening allergic reaction. Intradermal injections aren't necessarily less painful or easier to administer. Remediation: Intradermal injection
The health care provider prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102°F (38.8°C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place. mL
20.3 Explanation: The following formula is used to calculate drug dosages: dose on hand/quantity on hand = dose desired/X. In this example, the equation is as follows: 160 mg/5 mL = 650 mg/X, so then X = 20.3 mL.
A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. Which intervention is most important for the nurse to perform? Maintain a patent airway. Start feedings right away. Let the parents hold the neonate right away. Suction the trachea and stop when resistance is met.
Maintain a patent airway. Explanation: Maintaining a patent airway is essential until sedation from surgery for repair of a tracheoesophageal fistula and esophageal atresia wears off. Feedings usually aren't started for at least 48 hours after surgery. Parents are encouraged to participate in the neonate's care, but not immediately after surgery. Tracheal suctioning should be done only with a premeasured catheter to avoid injury to the surgical site.
After undergoing a liver biopsy, the client should be placed in which position? Semi-Fowler's position Right lateral decubitus position Supine position Prone position
Right lateral decubitus position Explanation: After a liver biopsy, the client should be placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. The other positions wouldn't achieve this goal. Remediation: Percutaneous liver biopsy
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? The time of membrane rupture The frequency of contractions The presence of back pain The presence of bloody show
The time of membrane rupture Explanation: First, the nurse should ask the client when her membranes ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and the onset of contractions. After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or bloody show. Remediation: Premature rupture of membranes (PROM) patient care
A healthy, 6-month-old infant is brought to the well-baby clinic for a checkup. When checking the infant's anterior fontanel the nurse expects it to be: open. sunken. closed. bulging.
open. Explanation: The anterior fontanel is open in a healthy, 6-month-old infant. Normally, it closes between ages 9 and 18 months. It should feel flat and firm. A sunken fontanel indicates dehydration. Although coughing or crying may cause temporary bulging, persistent bulging and tenseness of the fontanel signals increased intracranial pressure. Remediation: Neurologic assessment, pediatric Health history interview and physical assessment, pediatric
A nurse is caring for a client who is unconscious. In which position should the nurse place the client? side-lying with the head of the bed elevated supine with the head turned to the side prone with the knees sharply flexed Trendelenburg with the body in straight alignment
side-lying with the head of the bed elevated Explanation: Positioning the unconscious client side-lying, with the head of the bed elevated, reduces the risk of airway occlusion by the tongue and aids the drainage of secretions. The other positions place the unconscious client at risk for aspiration.
A 13-year-old with structural scoliosis has Cotrel-Dubousset rods inserted. Which position would be best during the post-operative period? supine in bed side-lying semi-Fowler's high Fowler's
supine in bed Explanation: After placement of Cotrel-Dubousset rods, the child must remain flat in bed. The gatch on a manual bed should be taped, and electric beds should be unplugged to prevent the child from raising the head or foot of the bed. Other positions, such as the side-lying, semi-Fowler's, and high Fowler's positions, could prove damaging because the rods won't be able to maintain the spine in a straight position. Remediation: Scoliosis, pediatric
A nurse is reinforcing education for a client with pernicious anemia requiring vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program? "I'll take one vitamin B12 tablet every morning for 2 weeks." "I'll take a vitamin B12 tablet once each month for life." "I'll need an injection of vitamin B12 every month for life." "I'll only need daily injections of vitamin B12 until my blood count improves."
"I'll need an INJECTION of vitamin B12 every month for LIFE." Explanation: In pernicious anemia, the gastric mucosa does not secrete intrinsic factor, a protein necessary for vitamin B12 absorption. Without intrinsic factor, vitamin B12 replacements taken orally are not absorbed; therefore, vitamin B12 must be administered through the IM or deep subcutaneous route. The client must have vitamin B12 injections each day for two weeks initially, then weekly for several months, and then once each month for life. Remediation: Anemia (pernicious) Anemia (pernicious), long-term care
The nurse reinforces instructions about breathing exercises for a client with chronic bronchitis. Which information should the nurse include? "Inhale longer than you exhale." "Exhale through an open mouth." "Use diaphragmatic breathing." "Practice rhythmic chest breathing."
"Use diaphragmatic breathing." Explanation: In a client with chronic bronchitis, the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. A client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing, not chest breathing, increases lung expansion. Remediation: Breathing and relaxation exercises, physical therapy Bronchitis (chronic)
A 19-year-old client with cystic fibrosis is admitted to the hospital in acute respiratory distress. The client's mother tells a nurse that the client has been unable to get out of bed for the past month. While assessing the client, the nurse notes a stage II pressure ulcer on the client's sacrum. Which action is most important to include in the client's plan of care? 1 Turn and reposition the client every 2 hours, monitor the wound, and document findings. 2 Accurately document the appearance, size, location, and odor of the wound, and consult a wound care nurse. 3 Keep the wound clean and dry, and continue to monitor it. 4 Cover the lesion with a sterile gauze pad, and document findings.
Accurately document the appearance, size, location, and odor of the wound, and consult a wound care nurse. Explanation: A client who is on prolonged bed rest is at risk for developing pressure ulcers. The nurse assessing the client must accurately document the appearance, size, location, and odor of the wound. Then the nurse should consult the wound care nurse and notify the physician to establish a treatment plan. The client should also be turned and repositioned every 2 hours, but providing wound care for this client is most important. A stage II pressure ulcer requires intervention; the nurse shouldn't continue to monitor the wound or cover it without establishing a treatment plan. Remediation: Pressure ulcer management, long-term care
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method? Aspiration of gastric contents and testing for a pH less than 6 Instillation of 30 ml of water while listening with a stethoscope Cessation of reflex gagging Ensuring proper measurement of the tube before insertion
Aspiration of gastric contents and testing for a pH less than 6 Explanation: Aspiration of gastric secretions with a pH less than 6 indicates placement in the stomach. A pH greater than 6 would indicate placement in the intestine. Instillation of 30 ml of water is dangerous without prior assurance of proper feeding tube placement. The cessation of gagging that occurs during placement indicates the oropharynx is no longer being stimulated. Exact measurement of the distance between the nares and the stomach before insertion is impossible but should be estimated and marked. Remediation: Enteral tube feeding, gastric Inserting a nasogastric tube
The nurse is caring for a child undergoing cardiac surgery? Which home care instruction is most appropriate? 1 Maintain the prescribed medication regimen until the health care provider makes a change. 2 Maintain a sodium-restricted diet. 3 Routine dental care can be resumed. 4 Immunizations are delayed indefinitely.
Maintain the prescribed medication regimen until the health care provider makes a change. Explanation: Drugs such as digoxin and furosemide shouldn't be stopped abruptly. There are no diet restrictions, so the child may resume a regular diet. Routine dental care is usually delayed 4 to 5 months after surgery. Immunizations may be delayed 6 to 8 weeks after surgery.
An older adult client seeks help for chronic constipation. This is a common problem for older adult clients due to what factor related to aging? increased intestinal motility decreased abdominal strength increased intestinal bacteria decreased production of hydrochloric acid
decreased abdominal strength Explanation: Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly. A decrease in hydrochloric acid causes a decrease in absorption of iron and B12. An increase in intestinal bacteria actually causes diarrhea. Remediation: Constipation
When collecting data on a child with cellulitis, which symptoms would the nurse expect to find? 1 pale, irritated, and cold to touch 2 vesicular blisters at the site of the injury 3 fever, edema, tenderness, and warmth at the site 4 swelling and redness with well-defined borders
fever, edema, tenderness, and warmth at the site Explanation: Cellulitis is a deep, locally diffuse infection of the skin. It is associated with redness, fever, edema, tenderness, and warmth at the site of the injury. Vesicular blisters suggest impetigo. Cellulitis has no well-defined borders. Remediation: Cellulitis
A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would the nurse expect to find in this client? 1 hypertension 2 flank pain on the affected side 3 pain that radiates toward the unaffected side 4 no tenderness with deep palpation over the costovertebral angle
flank pain on the affected side Explanation: The client may report flank pain on the affected side because the kidney is enlarged and might have formed an abscess. Hypertension is associated with chronic pyelonephritis. The client would have tenderness with deep palpation over the costovertebral angle. Pain may radiate down the ureters or to the epigastrium. Remediation: Acute pyelonephritis
A client asks to be discharged from the health care facility against medical advice (AMA). Which action would the nurse do first? Take measures to prevent the client from leaving. Ask the client to sign an AMA form. Call a security guard to help detain the client. Notify the health care provider of the client's request.
Notify the health care provider of the client's request. Explanation: If a client requests discharge AMA, the nurse should notify the health care provider immediately. If the client cannot be convinced to stay, the health care provider will ask the client to sign an AMA form. This form releases the hospital from legal responsibility. If the health care provider is not available, the nurse should obtain the client's signature on the AMA form. A client who refuses to sign the form should not be detained; forced detention violates the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the health care provider that the client has left. Remediation:
A client states that he's uncomfortable lying in the hospital bed and can't sleep. The nurse checks the client's medication administration record and there's no sleep medication prescribed. How can the nurse best help this client? Notify the physician and request an order for a sleep aid. Turn on the client's television and close the door to his room. Allow the client to verbalize his concerns, then suggest measures to promote sleep. Provide a gentle backrub to promote relaxation and sleep.
Provide a gentle backrub to promote relaxation and sleep. Explanation: The nurse should first attempt nonpharmacologic measures to promote sleep, such as offering a gentle backrub. If nonpharmacologic measures fail, then the nurse should notify the physician and request an order for a sleep aid. Turning on the television increases stimulation and hinders rest. Offering suggestions doesn't help promote sleep. Remediation: Back care Hour of sleep care
A nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, what should the nurse instruct the client to do? "Sneeze with your mouth open." "Blow your nose frequently." "Clean your operated ear with a cotton-tipped applicator twice per day." "Resume bending when you are no longer experiencing any ear pain."
"Sneeze with your mouth open." Explanation: If sneezing cannot be avoided, the client should sneeze with his mouth open to prevent air pressure changes in the middle ear, which can dislodge the prosthesis and graft. Blowing the nose and coughing should be avoided. Small objects, such as cotton-tipped applicators, should not be inserted into the ear. Straining during a bowel movement and bending should be avoided for at least 2 to 3 weeks, or as instructed by the primary care provider. Remediation: Stapedectomy
The nurse is reinforcing education with the parents of a 3-year-old child diagnosed with rubella. The mother has just given birth to a second child. Which statement by the parent best indicates an understanding of the implications of rubella? "I will give my child aspirin for fever." "I'll ask the primary health care provider about giving the baby an immunization shot." "I don't have to worry because I've had the measles." "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." Explanation: Fetal defects such as deafness, cardiac defects, and motor and mental challenges can occur during the first trimester of pregnancy if the pregnant woman gets rubella. The parent who plans to tell the pregnant neighbor to stay away from the child, who has been diagnosed with rubella, understands these implications. Aspirin should not be given to young children because aspirin has been implicated in the development of Reye syndrome; acetaminophen should be used instead. Rubella immunization is not recommended for children until ages 12 to 15 months. A history of measles, or rubeola, does not provide immunity against rubella, or German measles. Remediation: Rubella
A client, who has a new above-the-knee amputation, refuses to look at the residual limb and refuses family visits. When the nurse attempts to speak with the client about the surgery, the client replies, "I do not want to discuss it." Which nursing intervention is appropriate? Avoid asking about the surgery to respect the client's wishes. Discuss the client's comments with the family. Provide support during the grieving process. Suggest a referral for a mental health examination.
Provide support during the grieving process. Explanation: The nurse must recognize these are signs of grieving and should support the client during this process. This client has lost a limb and is in a depressed state of grieving. The five stages of grief are denial, anger, bargaining, depression, and acceptance. A referral for a mental health examination is not warranted because this is a recent surgery. This client should be encouraged to talk about the client's feelings. The nurse should respect the client's privacy and not discuss the client's comments with the family. Remediation: Stump care
The nurse cares for a client who is postoperative right modified mastectomy. The client has a pressure dressing on the surgical site. Which priority care intervention should the nurse provide for this client? promoting adequate intake of fluids monitoring the client's right arm encouraging coughing and deep breathing inspecting the client's postoperative dressing
encouraging coughing and deep breathing Explanation: The nurse needs to encourage coughing and deep breathing to facilitate the movement of secretions and help prevent atelectasis. A client's fears of pain, tight dressings, and incision site tearing after a modified mastectomy tend to limit chest expansion and a willingness to cough and change positions. Promoting intake, monitoring the right arm, and inspecting the dressing are appropriate interventions but are not a priority over breathing. Remediation: Pressure dressing application Breast cancer
According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. The nurse can best promote the development of a hospitalized adolescent by: emphasizing the need to follow the facility regimen. allowing parents and siblings to visit frequently. arranging for tutoring in school work. encouraging peer visitation.
encouraging peer visitation. Explanation: Peer visitation gives the adolescent an opportunity to continue along the path toward independence and identity. Knowledge of the facility regimen prepares the adolescent for upcoming procedures but doesn't affect development. To achieve a sense of identity, the adolescent must gain independence from the family; in contrast, parent and sibling visits tend to encourage dependence on the family. Tutoring may help maintain a positive self-image relative to schoolwork but doesn't affect development. Remediation: Developmental considerations: Adolescents
A client recently diagnosed with colon cancer states, "I am having trouble sleeping because of thoughts of how life will change after surgery." What is the best response by the nurse? "I will request a chaplain to come and talk with you." "I will refer you to a cancer support group." "I will talk to the charge nurse about this." "I will sit and talk with you about how you are feeling."
I will sit and talk with you about how you are feeling." Explanation: The client is having trouble sleeping because of concerns about life changes. The client may be experiencing anxiety and powerlessness. Encouraging the client to verbalize feelings will help the nurse to determine how to assist the client and may reduce the client's anxiety. The other options do not directly address the client's comments and concerns. Remediation: Colorectal cancer
The nurse is caring for a client diagnosed with chronic renal failure. The foods to avoid include foods high in which substance? iron carbohydrates proteins fats
proteins Explanation: Proteins are restricted in clients with chronic renal failure because of metabolites. Iron, carbohydrates, and fat are not restricted. Remediation: Kidney disease (chronic
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. The nurse includes which instruction in the discharge teaching? "Continue to take antacids, even if your symptoms subside." "You may take antacids with other medications." "Avoid taking antacids containing magnesium if you develop a heart problem." "Take antacids with meals."
"Continue to take antacids, even if your symptoms subside." Explanation: Antacids decrease gastric acidity and should be continued even if the client's symptoms subside. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals. Remediation: Peptic ulcer
During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below how many beats per minute? 60 80 100 110
60 Explanation: The normal neonatal heart rate is 120 to 160 beats/minute. Heart rates lower than 60 beats/minute necessitate chest compressions and ventilator support. Remediation: Cardiopulmonary resuscitation (CPR), one-person, infant
A child hospitalized with right-sided heart failure is tearful and states, "My parents do not want me to have any activity and I always need to rest." Which action by the nurse is most appropriate? Explain to the child that becoming tired is a concern with this condition. Explain to the child that the parents are just showing love and care. Ask the child if he would like assistance in sharing concerns with the parents. Ask the child if he would like to visit the unit's playroom.
Ask the child if he would like assistance in sharing concerns with the parents. Explanation: Fatigue is a concern in a child with heart failure. Efforts should be made to ensure adequate periods of rest. Activity and play are normal needs for a child. Parents of chronically ill children may at times be overprotective. Encouraging a meeting with the parents and child may be of benefit to highlight the child's concerns. Explaining that fatigue is a concern and that there is parental love, while true, does not address the child's concerns. Visiting the playroom does not address the concerns.
A woman is in the third stage of labor after having just given birth to a healthy newborn. Which actions would be most important during this stage? Select all that apply. 1 assisting with skin-to-skin contact of the mother with the newborn 2 providing the woman with cool compresses to prevent overheating 3 encouraging the woman to breast-feed if appropriate 4 assisting the woman into a comfortable position 5 applying a heating pad to the episiotomy site
assisting with skin-to-skin contact of the mother with the newborn encouraging the woman to breast-feed if appropriate assisting the woman into a comfortable position Explanation: During the third stage of labor, the nurse should assist with skin-to-skin contact between the mother and the newborn, provide warm blankets to prevent shivering, encourage the woman to breast-feed if appropriate, assist the woman into a comfortable position, and apply ice to the episiotomy site.
The nurse is caring for a client who is taking an anticoagulant. The nurse should teach the client to: report incidents of diarrhea. avoid foods high in vitamin K. use a straight razor when shaving. take aspirin for pain relief.
avoid foods high in vitamin K. Explanation: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but diarrhea isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen should be used for pain relief. Remediation: Vitamin K administration, long-term care Warfarin sodium (See "drug-food interaction")
A nurse is gathering data about a neonate. The nurse suspects that the neonate is experiencing a metabolic response to cold stress based on which finding? dysrhythmia hypoglycemia elevated liver function tests increased blood pressure
hypoglycemia Explanation: Hypoglycemia occurs as the consumption of glucose increases with the increase in metabolic rate. Dysrhythmia and increases in blood pressure occur due to cardiorespiratory manifestations. Liver function declines in cold stress.
The nurse cares for an older adult client with sensorineural hearing loss admitted to the rehabilitation center after hip replacement surgery. Which problem should the nurse monitor this client for the risk of developing? impaired perception of the environment increased toxicity to pain medication diminished cognitive functioning incontinence of urine
impaired perception of the environment Explanation: The older adult client with sensorineural hearing loss may be at risk for altered perceptions related to an unfamiliar environment. Nothing in the case scenario indicates that the client is taking controlled substances for pain or that the client has cognitive function or incontinence issues. Remediation: Hearing loss
The physician prescribes lithium carbonate for a client who has just been diagnosed with bipolar disorder. Now the nurse is teaching the client about signs and symptoms of lithium toxicity, which include: skeletal muscle contractions, cogwheel rigidity, and a thick tongue. dry mouth, blurred vision, and urine retention. edema, orthostatic hypotension, and rash. lethargy, vomiting, and diarrhea.
lethargy, vomiting, and diarrhea. Explanation: Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop. Lithium doesn't cause extrapyramidal effects, such as skeletal muscle contractions, cogwheel rigidity, and a thick tongue, or cholinergic effects, such as dry mouth, blurred vision, and urine retention. The drug also doesn't cause edema, orthostatic hypotension, or rash. Remediation: lithium carbonate
A client reports being exposed to lice and thinks he or she may have them. Which observations made by the nurse would indicate the client's report is correct? diffuse, pruritic wheals oval, white dots stuck to the hair shafts pain, redness, and edema with an embedded stinger pruritic nodules and linear burrows of the finger and toe webs
oval, white dots stuck to the hair shafts Explanation: Nits, the eggs of lice, are seen as white, oval dots. Diffuse, itchy wheals indicate an allergic reaction. Bites from honeybees are associated with a stinger, pain, and redness. Pruritic nodules and linear burrows are diagnostic of scabies. Remediation: Lice
During data collection, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: somatic delusions. waxy flexibility. neologisms. nihilistic delusions.
waxy flexibility. Explanation: Waxy flexibility is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world. Remediation: Schizophrenia
A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to his mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." Which response by the nurse would help the mother understand her child's behavior? "Your baby's behavior indicates stranger anxiety, which is common at his age." "Children who behave that way are developing shy personalities." "Children at his age begin to fear pain." "Your baby's having a temper tantrum, which is common at his age."
"Your baby's behavior indicates stranger anxiety, which is common at his age." Explanation: Stranger anxiety, common in infants ages 6 to 8 months, may cause the child to cry, cling to the caregiver, and turn away from strangers. Typically, it occurs when the child starts to differentiate familiar and unfamiliar people. The child's behavior doesn't necessarily indicate shyness. According to Piaget, fear of pain characterizes the operational stage of development in school-age children, not infants. Temper tantrums are typical in toddlers who are trying to assert their independence; during a temper tantrum, children may kick, scream, hold their breath, or throw themselves onto the floor. Remediation: General guidelines for performing a procedure on a child Developmental considerations: Infants
A nurse needs assistance in getting an older adult client with confusion back into bed from the chair. The nurse leaves the client sitting alone in the room while going to find someone to assist with the transfer. While the nurse is gone, the client gets out of the chair, falls, and sustains an injury. What did the nurse fail to do? Properly educate the client about safety. Securely restrain the client in the chair. Document that the nurse left the client. Arrange for continual care of the client.
Arrange for continual care of the client. Explanation: By leaving the client, the nurse is at fault for abandonment. The nurse needs to ensure the client's safety at all times. The better course of action would have been to turn on the call bell or call for assistance from the client's room. Educating the client about safety measures does not exempt the nurse from responsibility for ensuring the client's safety. Additionally, the client's confusion plays a role in exactly how much the client would indeed understand. The nurse should not restrain the client without a health care provider's order. Moreover, restraints do not ensure the client's safety. The nurse who documents leaving the client is not excused from responsibility for ensuring the client's safety.
The nurse is teaching a client with osteomalacia how to take prescribed vitamin D supplements. The nurse stresses the importance of taking only the prescribed amount because high doses of vitamin D can be toxic. Early signs and symptoms of vitamin D toxicity include: GI upset and metallic taste. dry skin, hair loss, and inflamed mucous membranes. flushing and orthostatic hypotension. sensory neuropathy and difficulty maintaining balance.
GI upset and metallic taste. Explanation: GI upset and metallic taste are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headaches, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.
A licensed practical nurse (LPN) who typically works in the nursery is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to complete hourly rounds on the unit. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take? Inform the nurse-manager that the client needs to be assessed by a registered nurse. Tthe client to press the call button for a regular staff nurse. Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data. Find another LPN to help assess the client.
Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data. Explanation: Licensed professionals are always held accountable for practicing according to the level of education they've attained. The LPN is held accountable within the standards of practice for an LPN. It's within the scope of practice for an LPN to collect vital signs data and complete a cursory examination of the client's fundus and flow. The client shouldn't be left alone until data collected indicates it's safe to leave the room. If the client is unstable, the LPN needs to stay with her and call for help.
The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure? 1 Position the child with the head hyperextended. 2 Place a hand under the child's head for support. 3 Use pillows to prop the child into the sitting position. 4 Work a padded tongue blade or small plastic airway between the teeth.
Place a hand under the child's head for support. Explanation: Placing a hand or a small cushion or blanket under the child's head will help prevent injury. Position the child with the head in midline, not hyperextended, to promote a good airway and adequate ventilation. Don't attempt to prop the child up into a sitting position, but ease him to the floor to prevent falling and possible injury. Don't put anything in the child's mouth because it could cause infection or obstruct the airway. Remediation: Seizure disorder, pediatric
A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What should the nurse do first? Refer the parent to a support group such as Parents Anonymous. Report the incident to the proper authorities. Prepare the child for foster care placement. Restrict the parent from the child's room.
Report the incident to the proper authorities. Explanation: The nurse is required by law to report all incidents of suspected child abuse. Once the appropriate authorities have been notified, the child can be placed under protective custody. Later, the nurse may need to prepare the child for foster care placement. After reporting suspected abuse, the nurse should allow the parent to visit and help care for the child. During these visits, the nurse should exhibit and reinforce positive parenting behaviors. Remediation: Suspected child abuse assessment
The nurse at a substance abuse center is talking to a probation officer on the phone. The probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement best describes the nurse's response? correct because she didn't give out information about the client a violation of confidentiality because she informed the officer that the client wasn't there a breach of the principle of veracity because the nurse is misleading the officer illegal because she's withholding information from law enforcement agents
a violation of confidentiality because she informed the officer that the client wasn't there Explanation: The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
A 10-month-old infant with bacterial meningitis was just started on antibiotic therapy. Which nursing action is especially important in this situation? Wear a mask while providing care. Flex the child's neck every 4 hours to maintain range of motion. Administer oral gentamicin. Encourage the child to drink 3,000 mL of fluid per day.
Wear a mask while providing care. Explanation: With bacterial meningitis, respiratory isolation must be maintained for at least 24 hours after beginning antibiotic therapy. Wearing a mask is an important part of respiratory isolation. Moving the child's head to maintain range of motion would cause pain because his meninges are inflamed. Gentamicin is never administered orally. Encouraging 3,000 mL of fluid would cause overhydration in a 10-month-old infant and place him at risk for increased intracranial pressure. Remediation: Meningitis, pediatric
A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline? "You'll need more insulin when you exercise or increase your food intake." "You'll need less insulin when you exercise or reduce your food intake." "You'll need less insulin when you increase your food intake." "You'll need more insulin when you exercise or decrease your food intake."
You'll need less insulin when you exercise or reduce your food intake." Explanation: Exercise, reduced food intake, hypothyroidism, and certain medications decrease the insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase the insulin requirements. Remediation: Diabetes mellitus, type 1 Insulins (short-acting)
A family member brings a client to the emergency department that has allegedly taken approximately 20 pills from a bottle of narcotics. The nurse obtains a blood pressure of 90/56 mm Hg, heart rate of 46, and a respiratory rate of 10 breaths/minute. What is the priority nursing intervention? maintain a patent airway start an I.V. of lactated Ringers solution obtain a blood and urine drug screen begin cardiopulmonary resuscitation (CPR)
maintain a patent airway Explanation: The priority intervention is to maintain a patent airway because the respiratory rate is decreasing and the client may have a respiratory arrest. CPR is not indicated at this time because there is a respiratory and heart rate. A urine and blood drug screen may be obtained at a later time after the client is stabilized along with the I.V. Remediation: Level of consciousness (decreased)
The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should: 1 administer oxygen. 2 have the client take deep breaths and cough. 3 place the client in high Fowler's position. 4 perform chest physiotherapy.
place the client in high Fowler's position. Explanation: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema. Remediation: Pulmonary edema
A client who is 27 weeks' pregnant arrives at the health care provider's office reporting fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. About which condition does the nurse anticipate reinforcing education? asymptomatic bacteriuria bacterial vaginosis pyelonephritis urinary tract infection (UTI)
pyelonephritis Explanation: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. Asymptomatic bacteriuria does not cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Remediation: Acute pyelonephritis
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: 1 develops rapidly and is temporary. 2 occurs by antibody transmission. 3 results from exposure of an antigen through immunization or disease contact. 4 may be transferred by mother to neonate.
results from exposure of an antigen through immunization or disease contact. Explanation: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it's temporary. Passive immunity may be transferred by mother to neonate. Remediation: Rho(D) immune globulin, human (IGIM)
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? Encouraging coughing and deep breathing Promoting carbohydrate intake Limiting fluid intake Providing pain-relief measures
Limiting fluid intake Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain. Remediation: Kidney injury (acute)
A 4-month-old rolls out of the crib and suffers a fractured skull when the nurse who's bathing him turns her back to pick up a towel. As a follow-up to the incident the nurse-manager asks the nurse to document how she could have prevented the injury. Which statement by the nurse is best? "I should have kept the side rails of the crib up during bathing." "I should have carried the infant with me when I had to pick up a towel." "I should have kept one hand on the infant when I turned my back on him." "I should have propped the infant on his side with a pillow to keep him from rolling."
"I should have kept one hand on the infant when I turned my back on him." Explanation: Whenever a nurse must turn her back from an infant during any procedure, she should always keep one hand firmly on the infant to prevent him from falling. The side rail should be down on the side from which the nurse is giving care to prevent strain on the nurse's back. The nurse shouldn't carry the infant during bathing because the wet conditions could cause her to drop the infant. Pillows might not have prevented such a fall and shouldn't be used with infants because of the risk of suffocation. Remediation: Fall prevention, pediatric Hospital bed preparation, pediatric
