NCLEX part II
A first-time mother is concerned that her 6-month-old infant is not gaining enough weight. What should the nurse tell the mother?
"Birth weight doubles by 6 months of age."
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
"No, it can initiate premature uterine contractions."
A client has a prescription for an oil retention enema and a cleansing enema. The client asks the nurse to explain the purpose of the enemas. What is the most accurate response by the nurse?
"Oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement."
The nurse is coaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which question?
"What activities are most important for you to be able to maintain control of your diabetes?" Empowerment is an approach to clinical practice that emphasizes helping people discover and use their innate abilities to gain mastery over their own condition. Empowerment means that individuals with a health problem have the tools, such as knowledge, control, resources, and experience, to implement and evaluate their self-management practices. Involvement of others, such as asking the client about family involvement, implies that the others will provide the direct care needed rather than the client. Asking the client what the client needs to know implies that the nurse will be the one to provide the information. Telling the client what is required does not provide the client with options or lead to empowerment.
A nurse is assessing a pregnant client in the second trimester. The nurse weighs the client, then compares the current and previous weights. During the second trimester, how much weight should the client gain per week?
1 lb (0.45 kg)
when do you notify a healthcare provider of a pt fall?
ALWAYS
What is an acceleration?
Accelerations are transient rises in the FHR that are normally caused by fetal movements and uterine contractions.
When assessing an adolescent for scoliosis, what should the nurse ask the client to do?
Bend forward at the waist with arms hanging freely.
A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?
Contact the previous nurse requesting that the nurse correct the error. The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.
What is an expected assessment finding when caring for a client with a percutaneous feeding tube?
Dark pink stoma without drainage
The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication?
Encourage the mother to breastfeed the infant.
what are enteric precautions?
Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material.
What is Meniere's disease?
Inner ear disease that results from a labyrinthine dysfunction creating increased hydraulic pressure within the inner ear Increased pressure causes severe vertigo, fluctuating sensorineural hearing loss, and tinnitus Usually involves only one ear (unilateral) but can later progress to the other ear (bilateral)
to prevent a pressure ulcer from forming, should you tuck covers tightly into the foot of the bed?
NOOO
What is Naegele's rule?
Naegele's rule is one method of determining the estimated due date. When using Naegele's rule, add 7 days to the first day of the last menstrual period, and count back 3 months. Naegele's rule may be used with other assessment findings, especially in situations when the last menstrual period is in question. Naegele's rule does not use dates of intercourse nor adding 9 months to the last menstrual period to determine the due date.
s/s phlebitis
Phlebitis would be evidenced by redness at the cannula tip and along the length of the vein.
For a child with hemophilia, what is the most important nursing goal?
Preventing bleeding episodes
What is a prolonged deceleration?
Prolonged decelerations, also known as reflex bradycardia, are decreases in the FHR that last 60 to 90 seconds. These decelerations occur in response to sudden vagal stimulation. May indicate fetal distress.
The nurse is planning with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy. What should the nurse do?
Provide positive reinforcement for skills achieved.
What marks the first stage of labor?
Regular mild contractions, which repeat at 5- to 10-minute intervals and last 30 to 45 seconds each, signal the onset of labor's first stage.
Which statement regarding heart sounds is correct?
S1 is loudest at the apex, and S2 is loudest at the base.
A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
Sew thick padding into the elbows and knees of the child's clothing.
s/s of infiltration
The assessment findings of pallor, swelling, skin that is cool to the touch at the intravenous insertion site, and a normal WBC count all indicate infiltration. The infusion would be discontinued and restarted in a different site.
The client is discussing the client's medication history with the nurse. During the discussion, the client pulls out a list of the prescribed medications, which include fish oil and St. John's Wort. What is the nurse's understanding of why these alternative therapies are used by the client?
The client has a history of depression. The client has a history of depression. Fish oil and St. John's wort are alternative therapies to treat depression.
fourth stage of labor
The fourth stage of labor begins with placental expulsion and extends through the next 1 to 2 hours, in which the patient's body rests and begins adjusting to the postpartum state. The fourth stage is a crucial time for the patient and neonate, because both are recovering from the physical process of birth and becoming acquainted with each other.3
Second stage of labor?
The second stage of labor begins with full cervical dilation (10 cm) and complete effacement (100%). By the time the patient is transitioning to the second stage of labor, contractions are strong, occur every 2 to 3 minutes, and last 60 to 90 seconds each. At this point, the patient may have difficulty maintaining control due to the intensity of labor, lose control of breathing techniques, and experience nausea and vomiting. This stage commonly ends within 1 hour, concluding with birth.
What is an early deceleration?
When decelerations occur at the same time as uterine contractions, they are called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress.
A nurse is assessing a client who is receiving clozapine. The nurse reviews the chart. What should the nurse do next?
Withhold the clozapine, and notify the primary care provider. Because clozapine can cause tachycardia, the nurse should withhold the medication if the pulse rate is greater than 140 bpm and notify the physician. Giving the drug or telling the client to exercise could be detrimental to the client.
What is ataxia?
______ describes a lack of coordination while performing voluntary movements. It may appear as clumsiness, inaccuracy, or instability.
What kind of precaution is implemented for SARs?
airborne
The nurse should assess a client at risk for acute disseminated intravascular coagulation (DIC) for which early sign?
bleeding without history or cause There is no well-defined sequence for acute DIC other than that the client starts bleeding without a history or cause and does not stop bleeding. Later signs may include severe shortness of breath, hypotension, pallor, petechiae, hematoma, orthopnea, hematuria, vision changes, and joint pain.
The client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat?
broiled chicken, green beans, and cottage cheese
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates
cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.
The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?
droplet
At which time should the nurse anticipate assisting a client to breastfeed her neonate?
during the neonate's first period of reactivity
A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?
early decelerations A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they are called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress.
A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin
enhances protein synthesis.
The nurse should explain that the most common cause for the unhappiness some children experience when first entering school is due to which factor?
feelings of insecurity
A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief?
hands and knees
A child has discomfort and swelling around the IV insertion site. Which assessment should the nurse make first?
if the angiocatheter has come out of the vein Pain and swelling around the IV insertion site most likely indicates that the angiocatheter has come out of the vein. Swelling occurs as the fluid infuses into subcutaneous tissues. Other typical signs of infiltration include skin pallor and coldness around the insertion site.
The administration of medications during infancy is often necessary. The nurse needs to be concerned about the metabolism of these drugs. What concern regarding metabolism should the nurse consider when administering medications to an infant?
inefficient liver function
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention best determines the TPN is providing adequate nutrition?
monitoring the client's weight every day
How should penicillin be taken?
on an empty stomach
A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk?
pain radiating down the posterior thigh A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain.
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first?
preform a pelvic examination A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.
The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to
prevent seizures.
A client received magnesium sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate?
respiratory depression
A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?
tachycardia
The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The parent asks the nurse if this is abnormal. The nurse correctly responds that:
the 6-month-old does not normally have a pincer grasp yet.
What is the time limit for initiating thrombolytic therapy?
within 6 hrs of the onset of MI
The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
"Assume a reclining or flat position." The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?
"I'll eat plenty of fruits and vegetables." For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to take in these nutrients. The treatment of the ulcer may or may not include covering it; a wound nurse would create the best plan for the client. Redness in a wound is a sign of inflammation.
A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?
"Schedule follow-up visits with your physician for blood tests." A client taking phenytoin to control seizures must undergo routine blood testing to monitor for therapeutic serum phenytoin levels. Typically, the client takes the medication for 1 year after the original seizure, then is reevaluated for continued therapy. During phenytoin therapy, the client may drive and operate machinery. This drug may cause a decreased heart rate and hypotension.
A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response?
"Some jurisdictions have staffing laws that allow for nurses to be involved in staffing ratios."
An adolescent sustains a head injury and develops diabetes insipidus. The healthcare provider orders desmopressin, 10 mcg subcutaneously. When does the nurse assess the client to determine the need for an additional dose?
4 to 7 hours
What can restlessness & a high pitched cry indicate in a neonate?
An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP).
A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern?
Decrease supplemental feedings with formula. Routine formula supplementation may interfere with establishing an adequate milk volume because suckling the breast stimulates prolactin production. Prolactin is the hormone responsible for milk production. Vitamin C levels haven't been shown to influence milk volume. One alcoholic beverage generally tends to relax the mother, and facilitate the milk let-down reflex. Excessive consumption of alcohol may block milk let-down, though supply isn't necessarily affected. Frequent feedings are likely to increase milk production.
A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
Develop a written, individual turning schedule. A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 4 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing, despite the amount of helpers.
A nurse observes another nurse making social plans with a client and disclosing information of a personal nature. What would the observing nurse do in this situation?
Discuss the observation directly with the nurse.
third stage of labor
During the third stage of labor, strong but less painful contractions help expel the placenta, which normally emerges within 20 minutes after the neonate emerges. Signs that indicate normal separation of the placenta from the uterine wall include lengthening of the umbilical cord, a sudden gush of dark blood from the vagina, and a palpable change in uterine shape from disklike to globular.
When is epoetin alfa indicated?
Epoetin alfa is a colony-stimulating factor used help boost red blood cell count. Indications for use are a hemoglobin level < 10 g/dL. It will not improve white blood cells or components (neutrophils) or platelet counts.
The nurse is assessing the ears of an infant. What will the nurse do to best visualize the tympanic membrane?
Grasp the auricle with the nondominant hand, and pull down and back.
How long should the family of a hospice pt be provided w grief support?
If the client was cared for by hospice, the family should be provided grief support for up to a year following the death of the client.
What is anacephaly?
In anencephaly, the closure defect occurs at the cranial end of the neuraxis; as a result, part or the entire top of the skull is missing and the brain is severely damaged. Portions of the brain stem and spinal cord may also be missing. This condition is fatal.
What is a late deceleration?
Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends.
Which nursing intervention should be included in the care of an unconscious child with Reye's syndrome?
Place the child on a sheepskin. Placing the child with Reye's syndrome on a sheepskin helps to prevent pressure on prominent areas of the body. Rubbing lotion on the extremities stimulates circulation and helps prevent drying of the skin, and therefore shouldn't be avoided. Keeping extremities flexed can lead to contractures. Placing the child supine is contraindicated because of the risk of aspiration and increasing intracranial pressure. The supine position isn't appropriate because it puts pressure on the sacral and occipital areas.
A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy?
Provide a bed that is low to the floor.
The nurse needs to renew a registered nurse license. What evidence of competence may be required with each license renewal? Select all that apply.
Registered nurses license renewal identifies competence through evidence of continuing education and a negative criminal background check.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?
Remain in a side-lying position with the head elevated. The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted.
A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?
Request information about nursing responsibilities in caring for a client with a pump.
requirements of using restraints
Restraints are required to be removed or loosened every 2 hours to perform range-of-motion activities. The nurse should ensure 1 to 2 fingers can be placed between the restraint and the client's skin. A restraint order may not be written as a standing or an as-needed order. If you're restraining the client because of violent or self-destructive behavior, follow the Joint Commission, CMS, HFAP, and DNV GL-Healthcare USA guidelines for order limits (unless your facility has more restrictive guidelines): 4 hours for adults ages 18 and older, 2 hours for children and adolescents ages 9 to 17, and 1 hour for children younger than age 9. The order may be renewed according to the time limit for a maximum of 24 consecutive hours. The restraints must be secured to a non-movable part of the bed with a quick-release knot.
A client is to receive an IM injection using a Z-track injection technique. The nurse holds the gauze pledget against an IM injection site while removing the needle from the muscle. What is the intended outcome of this technique?
Seal off the track left by the needle in the tissue. When administering an injection using the Z track method, holding the gauze pledget against the site while removing the needle from the muscle helps to seal off the track left by the needle in the tissue.
To treat a urinary tract infection, a client is ordered sulfamethoxazole-trimethoprim. The nurse should teach the client that sulfamethoxazole-trimethoprim is most likely to cause which adverse effect?
Sulfamethoxazole-trimethoprim is most likely to cause diarrhea. Nausea and vomiting are other common adverse effects. This drug rarely causes anxiety, headache, or dizziness.
A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make?
Testicular cancer is a highly curable type of cancer. Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger, not older, men.
The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client?
The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L.
The nurse is evaluating the therapeutic goal of a client with history of cardiac dysrhythmias and newly completed radiofrequency catheter ablation. Which client-centered goal is most appropriate?
The client will have a regular heart rhythm from destruction of errant tissue of the heart. The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue in hopes of allowing impulse conduction to travel over appropriate pathways. The goal does not include dilation of blood vessels or reperfusion of heart tissue. There is no stimulation of the heart.
The healthcare provider orders a new medication for a 5-year-old client. The nurse educator asks the student, "What is a medication dose affected by?" What is the best response by the student? Select all that apply.
The drug dose is affected by weight and disease state, not by body build, height, or intake and output.
A parent calls the pediatric clinic to express concern over the child's eating habits. The parent says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of:
The nurse knows that erratic eating is typical of toddlers because the physiologic need for food decreases at about age 18 months as growth declines from the rapid rate of infancy. The toddler also develops strong food and taste preferences, sometimes eating just one type of food for days or weeks and then switching to another.
The nurse is observing a new graduate nurse instill eyedrops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which step is incorporated into the procedure?
The nurse's hand is stabilized on the client's forehead while instilling the drops. Correct technique for instilling eyedrops includes the nurse bracing his or her hand on the client's forehead while instilling the medication. The client should be instructed to gently apply pressure over the inner canthus to prevent systemic absorption of the drug but is not told to apply pressure to the eyes. The medication should be instilled in the client's lower conjunctival sac. To protect the cornea, the nurse should instruct the client to look up while the drops are being instilled.
A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?
The oxygen tubing is pinched. Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.
What is the purpose of a tocolytic?
Tocolytics are used to stop uterine contractions.
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate?
a gelatin dessert Gelatin desserts contain little or no potassium and can be served to a client on a potassium-restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.
A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis?
a low-protein diet with a prescribed amount of water Although dialysis removes water, creatinine, and urea from the blood, the client's diet must still be monitored. A high-protein diet is not recommended for renal clients. Eating too much protein may cause urea to build up more quickly. Water intake must be monitored, so unlimited water is not a correct choice. The client would be on a no-salt-added diet.
The parents of a 6-year-old child tell the nurse that they are concerned about the child's tonsils. On inspection, the nurse notes that the tonsils are large but not reddened or inflamed. How does the nurse interpret this finding?
a normal increase in lymphoid tissue Because lymphoid tissue develops rapidly in relation to size until age 10 to 11 years, lymphoid hyperplasia in the form of enlarged tonsils is normal until age 6 to 7 years. After this time, the tissue slowly atrophies.
During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that she smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate assessment, the nurse should monitor the client for symptoms of which complication?
abruptio placentae Dramatic vasoconstriction occurs as a result of smoking crack cocaine. This can lead to increased respiratory and cardiac rates and hypertension. It can severely compromise placental circulation, resulting in abruptio placentae and preterm labor and birth. Infants of these women can experience intracranial hemorrhage and withdrawal symptoms of tremulousness, irritability, and rigidity. Placenta previa, ruptured uterus, and maternal hypotension are not associated with cocaine use. Placenta previa may be associated with grand multiparity. Ruptured uterus may be associated with a large-for-gestational-age fetus.
The nurse performs the initial assessment and reports the following findings to the health care professional: The client's contractions started 5 hours ago and are now coming every 3 minutes and lasting for 60 seconds. The cervix is 100% effaced and 5 cm dilated, the membranes are intact, and the presenting part is well applied to the cervix and is at -1 station. The nurse recognizes that the client is in which stage or phase of labor?
active Because the cervix is dilating (5 cm) and has fully effaced (100%), the woman appears to be in active labor. Active labor, which is the latter phase of the first stage of labor, is characterized by cervical dilation of 4-7 cm. This client's regular uterine contractions are effective in facilitating fetal descent through the pelvis because the presenting part is well applied on the cervix and is at -1 station.
An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse's priority should be the potential for
aspiration
Which drug delivery system most effectively reduces the likelihood of medication errors?
automated An automated drug delivery system most effectively reduces the likelihood of medication errors by automatically dispensing the drug. Medication errors can still occur with this method but are less likely than with floor stock, unit-dose, and individual prescription methods.
A nurse in a psychiatric inpatient unit is caring for a client with generalized anxiety disorder. As part of the client's treatment, the psychiatrist orders lorazepam, 1 mg by mouth three times per day. During lorazepam therapy, the nurse should remind the client to:
avoid caffeine. Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for clients receiving lithium.
When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly?
blood pressure
An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin?
cephalosporins
The nurse is to instill drops of phenylephrine hydrochloride into the client's eye prior to cataract surgery. What is the expected outcome?
dilation of the pupil and constriction of blood vessels
What is Cushing's syndrome?
excessive cortisol production s/s Thin hair (see Recognizing Cushing syndrome) Moon face Hirsutism Buffalo hump Thin extremities Muscle wasting and muscle weakness Petechiae, ecchymosis, and purplish striae Skin atrophy Hyperpigmentation, especially on the face, neck, and back of the hands Delayed wound healing
A nurse is caring for a young child who is experiencing verbal tics and motor tics such as eye blinking and protruding the tongue. Based on this assessment, which medication would the nurse consider administering?
haloperidol Haloperidol is the drug of choice for treating Tourette syndrome. Fluoxetine, fluvoxamine, and paroxetine are antidepressants and are not used to treat Tourette syndrome.
A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage?
milk A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.
A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care?
monitoring intake and output Oxytocin has an antidiuretic effect; prolonged IV infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Therefore, the nurse should monitor intake and output closely. It isn't necessary to insert a catheter. Clients in labor do not have oral fluid restrictions. There is no need for the client to maintain complete bed rest.
A woman with chronic acquired immunodeficiency disorder (AIDS) tells the nurse at the women's health center that she is sexually active but has not had a gynecological exam for more than 3 years. What important information is essential to include in providing health education for the client?
safe sex education to prevent the risk of infection
Which change does a nurse demonstrate when helping a young mother adjust to the birth of her child?
situational Adjustment to the birth of a child is an example of a situational change, which arises from interaction between individuals and their environment. Because pregnancy is a 9-month process, the change isn't unplanned. Adjustment to maturational change refers to maturation associated with puberty. Physiologic change refers to events associated with aging and menopause.
A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is
skin traction applied to a lower extremity, with the extremity suspended above the bed.
Twenty-four hours after a client has given birth, the nurse documents that involution is progressing normally after palpating the client's fundus at which location?
slightly below the level of the umbilicus
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to
support the joint where the tendon is being tested. The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.
A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity?
the intact membranes An FSE may not be applied with intact amniotic membranes. In order to reach the fetal scalp and apply the electrode, the membranes must be ruptured, the cervix must be dilated a minimum of 2 cm, and the presenting part must be accessible by vaginal exam. An amniotomy must be performed instead. Bloody show may be present and uterine contractions may occur regardless of whether the membranes are ruptured.
A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction?
the pt has been exposed to Mycobacterium tuberculosis.
A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason?
to prevent Rh-positive sensitization with the next pregnancy
The nurse is preparing to administer vasopressin to a client who has undergone a hypophysectomy. What is the purpose of the medication?
to replace antidiuretic hormone (ADH) normally secreted from the pituitary After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH; therefore, vasopressin is administered. Somatropin or growth hormone is used to treat growth failure. SIADH results from excessive ADH secretion. Vasopressin is not used to treat cerebral edema.
What is isoniazid used for?
tuberculosis
Which type of mouth care is most appropriate when the nurse is caring for a client with dentures who has severe stomatitis?
using a soft toothbrush to provide oral hygiene A soft toothbrush, Toothette, or gauze pad should be used to provide oral hygiene at least every 2 hours to promote client comfort and prevent superinfection.Commercial mouthwash is contraindicated because of high alcohol content that is irritating to inflamed mucosa.Oral swabs with an astringent should be avoided because they are drying and also can promote bacterial growth.
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note
yellow sclerae. Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.
What is myasthenia gravis?
-Acquired autoimmune disorder characterized by abnormal fatiguability of striated (skeletal) muscles, most commonly the extra-ocular, pharyngeal, facial, and respiratory muscles -Sporadic but progressive muscle weakness that is exacerbated by exercise and repetitive movement and improves after rest -Initial symptoms related to cranial nerves -Possibly life-threatening if respiratory system involvement occurs
When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of
10 to 20 mm Hg.
A woman is using progestin injections for contraception. When does the nurse instruct the client to return for her next injection?
3 months
The nurse meets with a client in the outpatient clinic who is suicidal and refuses participate in creating a suicide safety plan. What should the nurse do next?
Arrange for immediate hospitalization on a locked unit.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. Enunciating each word is unnecessary. The nurse should allow the client at least 30 seconds to respond to questions or follow a command. Clients with aphasia may need more time to process and understand information. Nurses should use short, simple sentences and avoid frequently changing topics. It is unnecessary to speak in a louder or softer voice than normal.
Describe the different kinds of lochia found postpartum?
Lochia rubra is a red discharge that occurs 1 to 3 days after birth. It consists almost entirely of blood with only small clots and mucus. Lochia alba is a creamy white or colorless discharge that occurs up to 14 days' postpartum and may continue for up to 6 weeks. Lochia serosa is a pink or brownish discharge that occurs 3 to 10 days postpartum. Thrombic isn't a term used to describe lochia.
When providing oral hygiene for an unconscious client, the nurse must perform which action?
Place the client in a side-lying position.
What is the antidote for warfarin?
Vitamin K
When educating the client with type 1 diabetes, the nurse knows that more education is needed when the client says:
"I will be able to switch to insulin pills when my sugar is under control." Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. The need to eliminate sugar, give insulin, and receive proper foot care are all items that indicate the client understands the teaching.
When a client has an acute attack of diverticulitis, what should the nurse do first?
Assess the client for signs of peritonitis. The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess, and fistula formation, bowel obstruction, ureteral obstruction, and bleeding. A computed tomography (CT) scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The client is kept on NPO status; parenteral fluid therapy is provided.
An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action?
Gradually reduce the rate of the TPN per health care provider order. Gradually reducing the rate will avoid a sudden loss of the highly concentrated solution of amino acids, glucose, and other nutrients, and allow the child's body to adapt. Infusing a glucose solution after discontinuing TPN is not necessary when the infusion rate has been tapered. A glucose solution may need to be infused if discontinuation was sudden to avoid an abrupt drop in blood glucose. Administering insulin after discontinuing TPN would result in hypoglycemia. The pharmacy should be notified so that additional TPN is not prepared, but that is not a priority nursing action.
As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?
Return to the car and call the police. The nurse needs to consider his/her own personal safety in this situation and how he/she will be the most help to this family. The nurse needs to get some back-up support before entering the house due to the potential for violence. The nurse should not go into the home if his/her safety is in danger.
The nurse is assessing for oxygenation in a client with dark skin. Where will oxygenation be most evident on this client?
buccal mucosa The nurse should examine the buccal mucosa, along with the conjunctiva and sclera, nail beds, palms, soles, lips, and tongue to assess for oxygenation in a client with dark skin.
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?
metabolic alkalosis Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.
What is the antidote for heparin?
protamine sulfate
A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?
an irregular apical pulse Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as
Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. How should the nurse best intervene?
Assess the client's injury, notify the healthcare provider, and document the incident. The nurse should assess the injury, notify the healthcare provider, and thoroughly document the incident in accordance with facility protocol. Even though a patient with somatic symptom disorder is likely to have many physical complaints, the nurse should thoroughly investigate each complaint to avoid overlooking a serious problem. The nurse should always notify the healthcare provider of the findings in accordance with facility protocol.
A nurse is developing a nursing diagnosis for a client. Which information should be included?
factors influencing the client's condition A nursing diagnosis is a written statement describing a client's actual or potential health condition. It includes a specified diagnostic label, factors that influence the client's condition, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process. A problem-focused nursing diagnosis contains three components: a problem, related factors, and the defining characteristics: _____ r/t______AEB______
When providing intermittent nasogastric feedings to an infant with failure to thrive, which method is preferred to confirm tube placement before each feeding?
verifying that the gastric pH is less than 5.5 For children receiving intermittent gavage feedings, the best method to verify the tube placement before each feeding is to aspirate a small amount of gastric contents to verify that the pH is acidic. A pH of 5.5 or less should indicate correct placement in most babies. Depending on the type of feeding tube used, an X-ray may be used to confirm the original tube placement, but use before every feeding would expose the child to unnecessary radiation. Air boluses are misleading because placement in the esophagus or respiratory tract may make the same sound in small infants. Charts might be helpful in determining initial tube insertion length, but do not substitute for nursing assessments.
The nurse teaches the client with a demand pacemaker that the device functions by providing stimuli to the heart muscle:
when the heart rate falls below a specified level. A demand pacemaker functions only when the heart rate falls below a certain level. A fixed-rate pacemaker stimulates heart contractions at a constant rate independent of the client's heart rate. Fixed-rate pacemakers are much less common than demand pacemakers.
Which item must the nurse consider when positioning a client for tracheal suctioning?
The semi-Fowler's position is the correct position for suctioning a client. The other answers are incorrect based on incorrect positioning of client for suctioning. The neck should be in neutral position.
A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?
Check on the client every 30 minutes while the restraints are on. the application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.
Good sources of dietary iron?
Good sources of dietary iron include red meats, poultry, green leafy vegetables, and dried fruits such as raisins. Milk products are poor sources of iron. Carrots are high in vitamin A.
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
Intrauterine infection.
After the nurse teaches a client and family about lithium therapy, which client statements indicates the need for further teaching?
"I need to eliminate salt in my diet." Clients receiving lithium need to have a consistent dietary intake of sodium to maintain a therapeutic serum lithium level of 0.6 to 1.2. A decrease in salt intake decreases lithium elimination, causing an increase in the serum lithium level.
The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order?
Deferoxamine is used for the treatment of iron overload by ridding the body of the extra iron. Montelukast is a bronchodilator used for chronic asthma. Ramipril is a antihypertensive used to treat hypertension. Flurazepam is a sedative/hypnotic that is used for insomnia.
A nurse is preparing to give an I.M. injection in the left leg of a 2-year-old child. Identify the area where the nurse should give the injection.
The vastus lateralis muscle, located in the thigh, is the muscle into which the nurse should administer an I.M. injection in the leg of a toddler. To give an injection into the vastus lateralis muscle, the nurse should divide the distance between the greater trochanter and the knee joints into quadrants. The injection should be given in the center of the upper quadrant.
Which assessment finding supports the administration of protamine sulfate?
aPTT 3.5-5 times normal
An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion?
"Actually it's not true that older people always stop having sexual activity when they get older."
During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the best response by the nurse?
"After menopause, the body's bone density declines, resulting in a gradual loss of height."
While interviewing a preschool-age girl who has been sexually abused about the event, which approach would be most effective?
"Play out" the event using anatomically correct dolls.
A parent is concerned about spoiling a 2-month-old child by picking up the child each time the child cries. Which suggestion should the nurse offer?
"Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs." The nurse should advise the parent to continue to pick up the crying infant because a young infant needs to be cuddled and held when crying. Because the infant's cognitive development isn't advanced enough to associate crying with getting attention, it would be difficult to spoil the infant at this age. Even if the diaper is dry, a gentle touch may be necessary until the infant falls asleep. Crying for 10 minutes wears an infant out; ignoring crying can make the infant mistrust caregivers and the environment. Infants cry for many reasons, not just when hungry, so the parent shouldn't assume the infant is crying from hunger.
While receiving disulfiram therapy, the client becomes nauseated and vomits severely. Which question should the nurse ask first?
"How much alcohol did you drink today?" The first question should be to ask the client how much alcohol he or she has had today because nausea with severe vomiting is a sign of an alcohol-disulfiram reaction. Asking whether the client feels flu symptoms is important after inquiring about alcohol intake. Foods cooked in an alcoholic beverage, such as wine, could also cause a reaction, but the reaction would be less severe because the alcohol dissipates with cooking. Asking how long the client has been taking disulfiram would be least important at this time.
A client calls the public health nurse with concerns that her one-month-old breastfed infant is not gaining weight as rapidly as her friend's newborn, who is the same age and formula-fed. What is the most helpful response by the nurse?
"I hear that you're concerned. Can you tell me more about your baby's growth pattern?" The most helpful response is the one that does not dismiss the new mother's concerns. It is normal for the new mother to seek reassurance and to compare the development of her newborn with others. While such comparisons should be discouraged, the nurse first addresses the client's concerns. By determining whether the growth pattern is within normal limits, the nurse can offer reassurance based on data instead of platitudes. Some academic studies suggest there is variation in weight gain between breastfed and bottle-fed infants, with the former gaining more in early months and the latter gaining more after six months; other studies, however, have found no statistically significant difference between the groups. In general, breastfed babies do tend to be leaner. The nurse has no evidence to support the conclusion that the friend is overfeeding her baby.
A nurse is teaching a parenting class about how to prevent thrush (oral candidiasis). Which statement by a parent indicates more teaching is required?
"I should rinse my child's glass after each use." A new glass should be used each time the child wants a drink. Thrush is a fungal infection. Children who regularly use a corticosteroid inhaler, use oral corticosteroids, or have received antibiotics disturbing normal flora are at risk. It can also occur chronically in children who have an immune disorder. To prevent reinfection parents should sterilize bottle nipples and pacifiers. Children with asthma should rinse their mouth well with water after using a corticosteroid, and if a spacer (reduces the amount of medicine in the mouth and throat) is used, it also needs to be rinsed.
A nurse is about to give a client with type 2 diabetes mellitus the prescribed insulin before breakfast on the first day postpartum. Which client statement indicates an understanding of insulin requirements immediately postpartum?
"I will need less insulin now than during my pregnancy." Postpartum insulin requirements are usually significantly lower than requirements during pregnancy. Occasionally, clients may require little or no insulin during the first 24 to 48 hours postpartum. Management of type 2 diabetes includes healthy eating, regular exercise, possibly diabetes medication or insulin therapy, and blood sugar monitoring. However, there is no way of knowing if the client will now be able to control the diabetes without insulin.
As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response?
"Medroxyprogesterone needs to be administered every 12 weeks."
A client has polycystic kidney disease. The client asks the nurse, "How did I get these fluid-filled bubbles on my kidneys?" How should the nurse respond to help the client understand risk factors for this disease?
"There is a higher incidence of polycystic kidney disease among blood relatives."
A healthcare provider orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
"To prevent evaporation of water from the hydrated epidermis."
A client asks the nurse why vitamin C intake is so important during pregnancy. How should the nurse respond?
"Vitamin C is required to promote blood clot and collagen formation." Vitamin C is required to promote blood clot and collagen formation. Vitamin C deficiency has been associated with premature rupture of the membranes and gestational hypertension.
A client being admitted to hospital is asked to sign a statement confirming that the client understands the rights to communicate information related to life support and resuscitation. The client asks the nurse why signing such a statement is necessary. What is the best response by the nurse?
"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them."
After trying for a year to conceive, a couple consults a fertility specialist. When obtaining a history from the husband, which question should the nurse ask?
"What childhood immunizations and illnesses did you have?" Mumps is a leading cause of male infertility. Dietary practices, hobbies, and travel are not likely contributors to male infertility.
A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?
"You must wait at least 1 year before becoming pregnant again."
According to Erikson's theory of development, chronic illness will have the greatest impact on which client?
11-year-old According to Erikson, an 11-year-old client is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old client because the client may not be able to accomplish tasks, which prevents the client from achieving a sense of industry. A 1-year-old (trust versus mistrust), a 3-year-old (autonomy versus shame and doubt), and a 41-year-old (generativity versus stagnation) are less likely to be impacted by the chronic illness; the younger age is less likely to be aware of the impact of chronic illness while the older adult would be more likely to adjust to the impact of chronic illness.
Which client has the highest risk of ovarian cancer?
45-year-old woman who has never been pregnant The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.
A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth?
72 hours
What is Reye's syndrome?
A rare syndrome of rapid liver degeneration and encephalitis in children who have been treated with aspirin during a viral infection.. Early symptoms include diarrhea, rapid breathing, vomiting, and severe fatigue. Symptoms such as confusion, seizures, and loss of consciousness need emergency treatment.
The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out?
Administer atropine sulfate. Atropine sulfate causes pupil dilation. This action is contraindicated for the client with glaucoma because it increases intraocular pressure. The drug does not have this effect on intraocular pressure in people who do not have glaucoma.
The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client?
Administer prescribed analgesics
Which intervention would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate?
Allow the child to assist in removing the dressings and applying the cream. Expressions of anger and combativeness are often the result of loss of control and a feeling of powerlessness. Some control over the situation is regained by allowing the child to participate in care. Although having parental support during the dressing changes may be helpful, this action does nothing to allow the child control. Giving the child permission to cry may help with verbalizing feelings, but doing so does nothing to provide the child with control over the situation. Although allowing the child to determine the time for dressing changes may provide a sense of control over the situation, doing so is inappropriate because the dressing changes need to be performed as prescribed to ensure effectiveness and healing.
A parent tells the nurse that the 4-year-old child is a very poor eater. What is the nurse's best recommendation for helping the parent increase the child's nutritional intake?
Allow the child to self feed. The best recommendation is to allow the child to self feed because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation but alone would not be an effective approach . It is important to offer new foods and choices, not just serve the child's favorite foods. Using a small table and chair would also enhance the primary recommendation of allowing the child to feed herself, but does not encourage socialization when eating.
The nurse is unable to find the health record (chart) for a client who has arrived for a clinic visit. Which is the best action by the nurse?
Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later.
A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?
Check on the client every 30 minutes while the restraints are on. The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.
A primigravid client who was successfully treated for preterm labor at 30 weeks' gestation had a history of mild hyperthyroidism before becoming pregnant. What instructions should the nurse include in the plan of care?
Continue taking low-dose oral propylthiouracil as prescribed. Although thioamides such as propylthiouracil and methimazole are considered teratogenic to the fetus and can lead to congenital hyperthyroidism (goiter) in the neonate, they still represent the treatment of choice. The client should be regulated on the lowest possible dose. Hyperthyroidism is associated with preterm labor and a low-birth-weight infant, so the client should contact the HCP if the contractions begin again. The client should not be urged to breastfeed because medications such as propylthiouracil and methimazole are secreted in breast milk. Tachycardia (not bradycardia) is associated with thyroid storm, a medical emergency, and should be reported to the HCP.
As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response?
Do nothing as this is normal behavior for a toddler. Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior.
While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots indicate which condition?
Epstein's pearls Epstein's pearls are tiny, hard, white nodules found in the mouth of some neonates. They are considered normal and usually disappear without treatment. Koplik's spots, associated with measles in children, are patchy and bright red with a bluish-white speck in the middle. Precocious teeth are actual teeth that some neonates have at birth. Usually, only one or two teeth are present. Candida albicans, or thrush, is not apparent in the mouth immediately after birth but may appear a day or 2 later. This infection is manifested by yellowish-white spots or lesions that resemble milk curds and bleed when attempts are made to wipe them away.
A nurse is assigned to an adolescent. Which nursing diagnosis is most appropriate for a hospitalized adolescent?
Fear related to altered body image is the most appropriate nursing diagnosis for a hospitalized adolescent because of the adolescent's developmental level and concern for physical appearance. An adolescent may fear disfigurement resulting from procedures and treatments. Separation is rarely a major stressor for the adolescent. Adolescents may have Fear related to the unknown, but they typically ask questions if they want information. A diagnosis of Ineffective coping related to activity restrictions may be appropriate for a toddler who has difficulty tolerating activity restrictions but is an unlikely nursing diagnosis for an adolescent.
A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do?
Find another nurse to cover the unit and send the nurse back to the surgery unit.
The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which plan would be best?
Spend brief intervals with the client each day. To promote a therapeutic relationship with a suspicious client, it is best to spend brief intervals with the client each day to develop trust, respect, and rapport.
An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do?
Make the bed with the bedsheet on top of the pressure mattress. To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.
Can metformin be given the morning of surgery?
Metformin should not be taken on the morning of surgery because of the risk for lactic acidosis.
What is the most important information for the nurse to include when teaching a client about metronidazole?
Mixing this drug with alcohol causes severe nausea and vomiting.
A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?
Monitor fetal heart tones. Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Performing a cervical examination would be contraindicated because any agitation of the cervix with a previa can result in hemorrhage and death for the mother or fetus. Preparing the client for a cesarean birth may not be indicated. A sonogram will need to be performed to determine the cause of bleeding. If the diagnosis is a partial placenta previa, the client may still be able to deliver vaginally.
A client asks to be discharged from the healthcare facility against medical advice (AMA). What should the nurse do first?
Notify the physician. If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.
A home care nurse is assessing a new client whose albumin level is 1.5 g/dL (15 g/L) and whose body weight is 25% below the ideal weight. What action should the nurse take?
Perform 3-day diet recall with client. Based on the client's body weight being 25% less than the ideal weight range and an albumin level of 1.5g/dL (15 g/L), the nurse suspects that the client's nutritional intake is less than what the body needs. The nurse should perform a 3-day diet recall with the client to compare dietary intake to the client's caloric needs. Enteral feedings are utilized when the client is able to digest food but has difficulty with ingestion of foods. There is no indication of this in the scenario. Capillary refill time is not directly impacted by nutritional intake and will not provide additional information relating to the client's nutritional status. Obtaining a protein level will not provide additional information relating to why the client's body weight is 25% less than ideal, so it is not the best answer choice.
A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that the blood pressure is 96/60 mm Hg, with a heart rate of 120 bpm. The client just vomited coffee-ground-like material. Based on these data what should the nurse do first?
Prepare to insert a nasogastric (NG) tube. The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status, and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting.
A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action?
Provide 15 to 20 grams of a fast-acting oral carbohydrate. The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subcutaneous glucagon or dextrose 50% IV if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.
What are s/s of phlebitis?
Redness, warmth, pain, and edema are all signs and symptoms of phlebitis.
The nurse is assisting a client diagnosed with dementia during meal time. Which nursing would best prevent complications?
Serve one course at a time with the appropriate utensil. The client with dementia may be at risk for less than required nutrition. Therefore, food and fluid intake is a priority. Eating one course at a time will prevent the client from becoming overwhelmed. A plate with too many choices, rushing a client with a short meal time, and expecting them to prepare a meal by opening containers may frustrate a client with cognitive deficits.
A nurse is caring for a client who is scheduled for amniocentesis. What will the nurse teach the client about this procedure?
She needs to empty her bladder prior to the procedure. While preparing a client for an amniocentesis, the woman should empty her bladder to avoid the risk of bladder puncture. The fetus will be monitored for 20 minutes prior to the procedure to evaluate fetal well-being and obtain a baseline to compare after the procedure. If the mother is Rh-negative, RhoGAM will be administered after the procedure to prevent potential sensitization to fetal blood. The fetal heart rate will be monitored continuously and the mother's vital signs every 15 minutes for an hour after the procedure. The nurse will assess the puncture site for bleeding. After recovery, the mother will go home to rest with instructions to report any bleeding or contractions. The mother should not have any contractions after the procedure.
A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do?
Take acetaminophen or ibuprofen. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.
A client asks the nurse to explain the meaning of her abnormal Papanicolaou (Pap) smear result of atypical squamous cells. The nurse should tell the client that an atypical Pap smear means that what has occurred?
The cells could cause various conditions and help identify a problem early.A nurse is caring for a young child who is experiencing verbal tics and motor tics such as eye blinking and protruding the tongue. Based on this assessment, which medication would the nurse consider administering?
What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor?
The nurse must file an incident or adverse event report. Nurses who witnessed the event are responsible for entering the information. Adverse reporting is a mechanism to find persistent problems; it is confidential and nonpunitive.
The nurse is teaching a pregnant client about exercises that may be helpful during pregnancy. Which points should the nurse include in the instruction? Select all that apply.
The nurse should explain that pelvic rocking exercises may help relieve lower back pain. Abdominal breathing exercises help relaxation and lift the abdominal wall off of the uterus. Kegel exercises help improve vaginal contractility and bladder control. The client may exercise regularly at least three times per week, but the duration of exercise should be limited to 35 minutes, especially in hot, humid, weather. The client should perform non-weight-bearing exercises such as swimming.
The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?
Urine output increases. Mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases.
Which action should the nurse perform to help alleviate a child's joint pain associated with rheumatic fever?
Use a bed cradle to avoid the weight of bed linens on joints. For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, which are not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.
A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?
Write "T.O." after the order and write out the physician's and nurse's names.
Parents of a 6-year-old tell a healthcare provider that the child has been having periods of unawareness with short periods of staring. Based on this history, the child is probably having which type of seizure?
absence This child is probably having typical absence seizures. Typical absence seizures have an onset between ages 3 and 12. This type of seizure is exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized by staring and a 3-cycle/second spike and waveform on an EEG. The attack lasts from 10 to 30 seconds and may occur as frequently as 50 to 100 times a day. No postictal or confused state follows the attack. A complex partial seizure causes a brief impairment of consciousness. A myoclonic seizure occurs in older children and is exhibited by lightning jerks without loss of consciousness. An abrupt increase in muscle tone, loss of consciousness, and marked autonomic signs and symptoms characterize the tonic seizure.
A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of
acupressure
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland?
adrenal cortex
A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment?
allowing extra time for the assessment When assessing an older adult client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.
A client being treated for iron deficiency anemia with ferrous sulfate continues to be anemic despite treatment. The nurse should assess the client for use of which medication?
aluminum hydroxide The nurse should assess the client for possible use of antacids such as aluminum hydroxide. Clients should take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.
While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem?
ambiguous genitalia
A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?
an isolation room three doors from the nurses' station A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation.
The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to:
avoid caffeine.
A client is receiving massage therapy to relieve pain. Which statement explains why massage is an effective way to relive pain?
blocks pain impulses from the spinal cord to the brain. A back rub stimulates the large-diameter cutaneous fibers, which block transmission of pain impulses from the spinal cord to the brain. It does not block the transmission of pain impulses or stimulate the release of endorphins. A back rub may distract the client, but the physiologic process of fiber stimulation is the main reason a back rub is used as therapy for pain relief.
How should a nurse prepare a suspension before administration?
by shaking it so that all the drug particles are dispersed uniformly The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form.
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
by supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.
In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery? Dribbling of urine:
can persist for several months. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery.
During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care?
caregiver role strain The nurse recognizes the mother's feelings of being overwhelmed with the issues concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support of other family members or friends, continue with psychoeducation, and help the family connect with a support group.
The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage?
clear, watery, yellow-tinged drainage Serous drainage is clear, watery plasma; sanguineous drainage is fresh, red bleeding; purulent drainage is thick and yellow; and purulent drainage with infection is beige to brown and foul smelling. White with sanguineous drainage and tenacious with yellow drainage are both indicative of an infection. Dark melena and foul smelling is indicative of a gastrointestinal bleed.
After evaluating a client for hypertension, a physician orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have?
decreased cardiac output and decreased systolic and diastolic blood pressure
The nurse assesses a child with ketoacidosis. What manifestations are supportive of the diagnosis of ketoacidosis?
deep, rapid respirations. This characteristic breathing pattern is known as Kussmaul respirations. Typically with ketoacidosis, the pulse rate would be more rapid and weak due to dehydration and loss of electrolytes. Typically with ketoacidosis, the skin would be dry due to dehydration. With ketoacidosis, hypotension results from the contracted blood volume secondary to dehydration.
Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living?
eliminating smoking and alcohol use Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux. They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing activity and rest, and avoiding high-stress situations may increase the client's general health and well-being, but they are not directly associated with hiatal hernia.
A depressed client has been taking a selective serotonin reuptake inhibitor (SSRI) in the evening, and is upset because he cannot perform sexually due to erectile problems. What is the nurse's best response?
engage in sexual activity prior to taking the drug
A nurse who provides care on a post-surgical unit is performing discharge teaching as a component of the nurse's effort to ensure continuity of care. Which is the primary goal of continuity of care?
ensuring a smooth and safe transition between different healthcare settings
A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that
enteric precautions must be continued. The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.
A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client?
ginseng Ginseng is used as an antihypertensive and lowers blood glucose. Kava is used for the treatment of anxiety and stress. Jojoba promotes hair growth and relief of skin problems. Melatonin aids in the treatment of insomnia.
The health care provider has prescribed salicylates for an older adult client with osteoarthritis to relieve pain. The nurse knows to assess the client for what potential adverse reaction?
hearing loss
Which factor would put the client at increased risk for pyelonephritis?
history of diabetes mellitus A client with a history of diabetes mellitus, urinary tract infections, or renal calculi is at increased risk for pyelonephritis. Others at high risk include pregnant women and people with structural alterations of the urinary tract. A history of hypertension may put the client at risk for kidney damage, but not kidney infection
If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to
immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy.
An 8-year-old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods. The nurse determines the child's biggest nutritional risk is which factor?
impaired oral motor control A child with severe cerebral palsy commonly has a lack of oral motor control that interferes with tongue control, chewing, and swallowing. This is the reason that this child is being fed pureed foods and fluids. Lack of tongue control commonly causes the child to push the food back out of the mouth while trying to chew and swallow. A child with cerebral palsy has a nonprogressive central nervous system insult.
which maternal lab should be monitored to determine RhoGAM administration to an RH positive pt?
indirect coomb's- for momma direct coombs-for baby
The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?
intake and output
A nurse is teaching a group of parents about urinary tract infections (UTIs) in children. What is the priority educational topic for this group of parents?
interventions to prevent UTIs Prevention is the most important goal of teaching about a preventable condition such as UTIs. The most preventive measures are simple hygienic practices that should be a routine part of daily care.
The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to which problem?
iron deficiency Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia. Drinking excess milk will not cause vitamin C, biotin, or folate deficiencies.
What is scoliosis?
lateral curvature of the spine
A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?
lean meats and low-fat milk Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake.
A parent reports that his 2-year-old child often falls when running. The nurse interprets this as indicating which normal aspect of a toddler's vision?
nearsightedness
A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client?
nitroprusside Excess catecholamine release occurs with pheochromocytoma and causes hypertension. The nurse should prepare to administer nitroprusside to control the hypertension until the client undergoes adrenalectomy to remove the tumor. Dopamine is used to treat hypotension, which is not associated with pheochromocytoma. Pheochromocytoma does not affect blood glucose levels, so insulin is not indicated in this client unless there is an underlying diagnosis of diabetes mellitus. Lidocaine is sometimes used to treat ventricular arrhythmias, which are not associated with pheochromocytoma.
A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of
nursing informatics. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.
In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?
orders for antibiotics Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.
Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?
preparing for mechanical ventilation As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway.
A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior?
preschool or toddler (age 2-5 years) Children in this age group are in Piaget's preoperational stage of cognitive development and relate pain as punishment for past behavior. A priority nursing action is to provide reassurance.
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?
prevent the development of ketosis. High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.
Which statement describes the term fetal position?
relationship of the fetus's presenting part to the mother's pelvis
When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:
safety needs. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.
The nurse is caring for a client with a percutaneous tube with an external retention flange. The nurse notifies the healthcare provider that the tension on the retention flange is excessive upon discovering what assessment finding?
skin breakdown at the stoma site Excessive tension on the external retention flange (bolster) of a percutaneous feeding tube can cause excessive pain, skin breakdown, and ulceration. The tube should be secured but not with excessive tension. Leaking of gastric contents can occur if the internal balloon is deflated or cracks, or if the stoma becomes enlarged. Nausea and diarrhea can be complications of dumping syndrome if a client is not tolerating the tube feedings, but not because the tube has excessive tension. Occlusion of the feeding tube often occurs from inadequate flushing before and after feeds and medications or infrequent flushing of a tube that is not currently in use.
The nurse is caring for an older adult who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which type of chair?
straight-back chair with elevated seat It is important that clients with rheumatoid arthritis maintain proper posture and body alignment to support joints and decrease pain and stiffness. Clients with hip pain will be most comfortable when sitting in a straight-back chair with an elevated seat. Elevated seats avoid excessive hip flexion and place less stress on the hip joints.
On discharge, a client who underwent left modified radical mastectomy expresses relief that "the cancer" has been treated. What is most important for the nurse to include in discharge teaching?
the need for continued breast self-examination on the right breast The client's statement regarding the "cancer" being treated indicates the need for further teaching regarding breast cancer. Having breast cancer on the left side puts the client at greater risk for cancer on the opposite side and chest wall. Therefore, the nurse should stress the importance of monthly breast self-examinations and annual mammograms. Although the tumor was found, it was large enough to require a mastectomy and could put the client at risk for metastasis. Follow-up appointments should be monthly for the first few months and then scheduled at the direction of the healthcare provider. A temperature of 99.9°F (37.7°C) does not require notification of the healthcare provider. It will be important for the client to increase protein and calories in order to promote wound healing. A high-carbohydrate, low-fat diet may not be appropriate for this client.
The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention?
Remove inner cannula and clean using universal precautions. When tracheostomy care is performed, sterile technique is used and standard precautions are not enough. The presence of an inner cannula provides direct access to the lungs for organisms, so sterile technique must be used to decrease the risk of infection. All other steps are appropriate.
what is Legionnaires' disease.
An acute bronchopneumonia produced by the gram-negative bacteria Legionella acquired from inhalation of contaminated aerosolized mist (from a water source) Illness ranging from mild (with or without pneumonitis) to serious multilobar pneumonia, with mortality as high as 50% with nosocomial infection The Legionella organisms enter the lungs after aspiration or inhalation of aerosolized mist from water sources.
A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?
Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying:
"I'll stop being contagious when I have a negative acid-fast bacilli test." A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when there is clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears.
The nurse is teaching a young female about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client makes which statement?
"I'll use one of the barrier methods of contraception." An alternative or additional method of birth control must be used because oxcarbazepine reduces the effectiveness of oral contraceptives. Higher doses of oral contraceptives will not help in achieving this purpose, but the client needs an additional or alternative method of birth control. The client does not need advice about when to start a family. A side effect of oxcarbazepine may be weight gain, but it is typically gradual.
The nurse is educating the client on interventions to prevent and reduce lymphedema. Which advice would the nurse include? Select all that apply.
Because obesity is a risk factor in the development of lymphedema, the client should be advised to lose weight through a healthy diet and exercise. A compression sleeve, measured and ordered from a specialist such as a physical therapist, should be worn to reduce movement of fluid out of capillaries and promote venous and lymphatic drainage. The right arm should not be used for blood pressure measurements or venipuncture to avoid interruption of blood flow and the risk for infection. A heating pad should not be applied to the right arm; it presents the risk for skin burns. Likewise, sunscreen should be used to avoid burns to the skin. The client should be advised to avoid activities that can cause breaks in the skin, providing a portal of entry for infection. For this reason, the client should wear gloves while gardening and should be taught the signs and symptoms of infection that require immediate medical attention.
A client with hyperthyroidism is to take saturated solution of potassium iodide (SSKI). What should the nurse do when administering this drug?
Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the SSKI in contact with the teeth.
A nurse meets frequently with a depressed client. The client stays mostly in his room and speaks only when addressed, answering briefly and abruptly while keeping his eyes on the floor. Initially, the nurse should focus on the client's ability to do which function?
Express himself verbally.
A school-age child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray?
Forks For a child with chorea-like movements, safety is of prime importance. Feeding the child may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with the tines.
A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. The client's physician orders neomycin, 4 g by mouth daily in four divided doses. The client's partner asks how neomycin decreases the serum ammonia concentration. How should the nurse respond?
Neomycin decreases the amount of ammonia-producing bacteria in the GI tract.
Normal urine output for a pt with a urinary catheter?
Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour.
The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?
Restrict sodium A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit?
The client will empty the drainage pouch frequently throughout the day. It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.
The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action?
closed glottis pushing Closed glottis pushing, or when a woman is told to hold her breath when she pushes typically while the nurse typically counts to 10, creates the Valsalva maneuver and is associated with decreased perfusion. Open glottis pushing, on the other hand, encourages women to listen to their own body cues for when to breathe and when to bear down. "Rest and descent" and squatting have positive influences on the second stage of labor and birth.
The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care?
perform proper hand hygiene
The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking gingko biloba to help manage her blood sugars. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication?
prolonged bleeding Gingko biloba is an herbal supplement commonly taken to improve memory or improve glycemic control. It has known antiplatelet effects and can put surgical clients at risk for bleeding. It not known to cause hypertension or sedation. Gingko's primary medication interaction relates to its potential to enhance the effects of other anticoagulants and lead to prolonged bleeding.
A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?
rectal, using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia.
The client in preterm labor is admitted to the hospital. To stop the client's uterine contractions, the nurse anticipates administering which medication?
terbutaline
The healthcare provider orders digoxin for the client with congestive heart failure. What should the nurse include in the client's teaching concerning the administration of digoxin? Select all that apply.
"Digoxin can cause swelling of the face, lips, or tongue." "Digoxin can cause a fast, irregular heartbeat."
Members of which religious tradition are likely to have the most stringent restrictions and parameters placed on their medical care?
Christian Scientist. Christian Science places significant restrictions on the use of drugs, medical procedures, therapies, and surgeries. The scope of these restrictions greatly exceeds that dictated by Hinduism, Protestant Christianity, and Buddhism.
A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine therapy. What is the treatment for dopamine extravasation?
elevating the affected limb, applying warm compresses, and administering phentolamine as ordered If extravasation occurs with dopamine administration, the nurse should elevate the affected limb, apply warm compresses, and administer phentolamine as ordered. The nurse shouldn't massage the limb or apply cold compresses.
The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort?
red, warm, palpable linear cord along the vein that is painful on palpation Superficial thrombophlebitis is associated with pain, warmth, and erythema. The nurse can request a prescription for warm packs to relieve the pain.
The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:
sudden, severe hypertension With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating.
Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids?
the importance of watching for signs of hyperglycemia Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise; insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism, resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone, and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state, which is a medical emergency manifested by signs of shock.
Caregivers of a 9-year-old client in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with the client. Which response is appropriate?
"At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it." By age 9 or 10, most children have an adult concept of death. Therefore, caregivers should discuss death with them in terms consistent with their developmental stage. In addition, school-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. While school-age children may fantasize about the unknown aspects of death, these fantasies may actually increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.
The nurse is teaching a client about levothyroxine. Which instruction should a nurse offer the client?
"Take the drug on an empty stomach." The nurse should instruct the client to take levothyroxine on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release). Taking the drug in the evening may lead to sleeplessness. Although vitamin C may increase the absorption of some medications such as iron, it does not have this effect with levothyroxine.
A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan?
"Use a barrier method of birth control for the rest of your cycle." Antibiotics may decrease the effectiveness of oral contraceptives. The client should be instructed to continue the contraceptives and use a barrier method as a backup method of birth control until the next menstrual cycle. The client should not stop taking her oral contraceptives, and there is no indication for or benefit to taking the antibiotic 2 hours after the contraceptive. There is no incidence of the adverse effects of increased hunger and fluid retention with the interaction of antibiotic therapy and oral contraceptives.
The health care provider has prescribed ciprofloxacin for a client who takes warfarin. What should the nurse instruct the client to do? Select all that apply.
A black box warning for ciprofloxacin is that ciprofloxacin may increase the anticoagulant effects of warfarin. The nurse should instruct the client to report increased bleeding and to monitor the prothrombin time and the international normalized ratio closely. The client can take the drug with or without food. Although there is a drug-food interaction and taking ciprofloxacin may increase the stimulatory effect of caffeine, the client does not need to eliminate caffeine but should report signs of stimulant effect. Ciprofloxacin may cause photosensitivity reactions; the nurse must advise the client to avoid excessive sunlight or artificial ultraviolet light during therapy. Clients must be advised not to crush, split, or chew the extended-release tablets.
A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?
I.V. tubing with a volume-control chamber Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours.
What is insensible fluid loss?
Insensible fluid loss is is loss of water from the body that is not easily measured, such as from the respiratory system, skin, and stool. The client with a fever of 102.5° Fahrenheit (39.2° Celsius) has insensible fluid loss through the skin. Fluid loss can occur through the lungs, but the client's respiratory rate is within normal limits, as are the blood pressure and heart rate. Urine output and chest tube drainage represent sensible fluid loss, as these outputs can be measured.
What is Addison's disease?
Insufficient secretion of hormones from the adrenal glands, Specifically, the adrenal glands produce insufficient amounts of the hormone cortisol and sometimes aldosterone, too. When the body is under stress (e.g. fighting an infection), this deficiency of cortisol can result in a life threatening Addisonian crisis characterized by low blood pressure.
A client is in the 38th week of her first pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action?
Review premonitory signs of labor with the client. Because the client is describing two premonitory signs of labor, Braxton Hicks contractions and tightening, the nurse should review these normal signs and reassure the client. An NST, used to assess fetal well-being, would be inappropriate unless the client reported changes in fetal activity. Urinalysis wouldn't be indicated unless the client reported symptoms of bladder inflammation, such as dysuria or urinary frequency or urgency. Because the client's findings are normal, she need not see the physician other than at her regular weekly appointment.
When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem?
aspiration Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is no sensory deficit.
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
To keep gastric pH at 3.0 to 3.5 To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity.
During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that her breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure?
Use her hand or a pump to express a small amount of breast milk before breastfeeding.
A nurse should expect to administer which medication to a client with gout?
colchicine A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout. Remediation:
A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence and has decreased the fluid intake because of the incontinence. What is the nurse's best response to the client?
"Drink eight glasses of water a day and urinate every 2 hours." Clients who have undergone TURP need to be instructed to maintain an adequate fluid intake despite urinary dribbling or incontinence. The client should be advised to drink at least eight glasses of water a day to dilute the urine and help prevent urinary tract infections. Maintaining a voiding schedule of every 2 hours can help decrease incidents of incontinence. Teaching the client Kegel exercises is also beneficial for strengthening sphincter tone. The nurse should not encourage the client to decrease fluids. It is not necessarily true that a decreased intake will cause renal calculi. Threatening the client with a catheter is not beneficial, and it is not the treatment of choice for a client who is experiencing incontinence from TURP.
A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The client asks the nurse how massage will help the pain. What is the best response by the nurse?
"Massage is point stimulation used for orthopedic and neurological conditions." Massage uses point stimulation of pushing and pulling of the skin, muscles, tendons, and ligaments to relieve orthopedic and neurological conditions. Massage will relax muscles, ligaments, and tendons. Massage is not widely used by hospitalized clients nor does it include the use of herbal supplements.
A client with erectile disorder is taking sildenafil. What instructions should the nurse give the client?
Expect an erection that may last up to 4 hours. An expected outcome of taking sildenafil is an erection that can last up to 4 hr. The nurse instructs the client to take the medication 1 hour before having intercourse as an erection will occur within 1 hour, and to take only take one tablet in 24 hours. The nurse advises the client to avoid taking the drug if he takes nitrate therapy, such as nitroglycerine, to avoid unsafe decreases in blood pressure.
A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks if the nursing assistant has been validated on obtaining fingerstick glucose readings. The nursing assistant does not have the skill validated, but has observed it many times and reports confidence in the ability to perform the skill. What should the nurse do?
Go with the nursing assistant into the client's room, and validate the nursing assistant's ability to perform the procedure. The nurse should validate the nursing assistant's ability to perform the fingerstick glucose procedure. The nursing assistant may not perform the procedure without having her skills validated by actually performing the procedure. Providing reading material about the procedure is not enough. If the nurse performs the procedure, she forfeits the opportunity to validate the nursing assistant's skills, and therefore underutilizes the nursing assistant.
Which foods are good sources of zinc?
Good sources of zinc include whole grains, meats, dairy products, and seafood. Fruits are good sources of vitamin C, and vegetables are a good source of many vitamins and minerals, but not zinc. Yeast is a good source of chromium, and legumes are a good source of copper, manganese, and molybdenum.
A client is diagnosed with diabetes mellitus. The physician orders 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes their hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?
Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; withdraw 35 units NPH. To avoid creating a vacuum, the nurse must inject exactly the same amount of air into a multidose vial to replace the amount of medication to be withdrawn. The nurse should follow these steps: (1) Inject air into the vial from which the second insulin dose will be withdrawn (isophane insulin). (2) Inject air into the vial from which insulin will be withdrawn first (regular insulin). (3) With the needle inserted into the regular insulin vial, withdraw the correct amount. (4) With 15 units of regular insulin in the syringe, carefully withdraw 35 units of NPH, for a total of 50 units in the syringe.
A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?
azithromycin Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.
A client prescribed an antipsychotic medication develops a high fever, muscle rigidity, and hypertension. The nurse immediately notifies the health care provider with concerns that the client is experiencing which life threatening condition?
neuroleptic malignant syndrome High fever, muscular rigidity, and altered consciousness are symptoms of neuroleptic malignancy syndrome, a potentially fatal complication of antipsychotic medications and major tranquilizers. Malignant hyperthermia has similar symptoms but is associated with anesthesia. Extrapyramidal side effects involve movement disorders, including rigidity, but do not include a fever and are not considered to be life threatening. Hypertensive crisis refers to a systolic blood pressure over 180 or diastolic blood pressure over 110.
