NCLEX Questions; Pediatrics: Respiratory, GI, GU, Cardiac

A child's parent asks the nurse what treatment the child will need for the diagnosis of strep throat. Which is the nurse's best response? 1. "Your child will be sent home on bedrest and should recover in a few days without any intervention." 2. "Your child will need to have the tonsils removed to prevent future strep infections." 3. "Your child will need oral penicillin for 10 days and should feel better in a few days." 4. "Your child will need to be admitted to the hospital for 5 days of intravenous antibiotics."

3. "Your child will need oral penicillin for 10 days and should feel better in a few days." The child will need a 10-day course of penicillin to treat the strep infection. It is essential that the nurse always tell the family that, although the child will feel better in a few days, the entire course of antibiotics must be completed.

Which child diagnosed with pneumonia would benefit most from hospitalization? 1. 13-year-old who is coughing, has coarse breath sounds, and is not sleeping well 2. 14-year-old with a fever of 38.6°C (101.5°F), rapid breathing, and a decreased appetite. 3. 15-year-old who has been vomiting for 3 days and has a fever of 38.5°C (101.3°F). 4. A 16-year-old who has a cough, chills, fever of 38.5°C (101.3°F), and wheezing.

3. 15-year-old who has been vomiting for 3 days and has a fever of 38.5°C (101.3°F). The teen who has been vomiting for several days and is unable to tolerate oral fluids and medication should be admitted for intravenous hydration.

55. The nurse is caring for a 3-year-old undergoing evaluation for celiac disease. Which of the following would the nurse expect to be included in the child's diagnostic workup? 1. Obtain complete blood count and serum electrolytes. 2. Obtain complete blood count and stool sample; keep child NPO. 3. Obtain stool sample and prepare child for jejunal biopsy. 4. Obtain complete blood count and serum electrolytes; monitor child's response to gluten-containing diet.

3. A stool sample for analysis of fat and a jejunal biopsy can confirm the diagnosis.

37. The nurse is caring for an 18-month-old infant whose cleft palate was repaired 12 hours ago. Which of the following should be included in the plan of care? 1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a pacifier. 2. Once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, and saltine crackers. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. 4. Use a Yankauer suction catheter on the infant's mouth to decrease the risk of aspiration of oral secretions.

3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. Pain medication should be administered regularly to avoid crying, which places stress on the suture line.

15. The nurse is caring for a 2-year-old hospitalized with MCNS. The edema has progressed from periorbital to generalized. The skin appears stretched, and areas of breakdown are noted over the bony prominences. The child has been receiving Lasix twice daily for several days. In order to reduce edema, which of the following does the nurse expect to be included in the treatment plan? 1. An increase in the amount and frequency of Lasix. 2. Addition of a second diuretic, such as mannitol. 3. Administration of intravenous albumin. 4. Elimination of all fluids and sodium from the child's diet.

3. Administration of intravenous albumin. In cases of severe edema, albumin is used to help return the fluid to the bloodstream from the subcutaneous tissue.

Which should the nurse administer to provide quick relief to a child with asthma who is coughing, wheezing, and having difficulty catching her breath? 1. Prednisone. 2. Singulair (montelukast). 3. Albuterol. 4. Flovent (fluticasone).

3. Albuterol. Albuterol is the quickrelief bronchodilator of choice for treating an asthma attack.

The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu? 1. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet 2. Pork chop, baked potato, cauliflower in cheese sauce, ice cream 3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries 4. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries Rationale: A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 3 is the only option that identifies low-fat and low-cholesterol foods.

A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? 1. Bed rest, with bathroom privileges only 2. Bed rest, keeping the affected extremity flat 3. Bed rest, with elevation of the affected extremity 4. Bed rest, with the affected extremity in a dependent position

3. Bed rest, with elevation of the affected extremity Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated and bed rest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in the remaining options are incorrect.

Which breathing exercises should the nurse have an asthmatic 3-year-old child do to increase her expiratory phase? 1. Use an incentive spirometer. 2. Breathe into a paper bag. 3. Blow a pinwheel. 4. Take several deep breaths.

3. Blowing a pinwheel is an excellent means of increasing a child's expiratory phase. Play is an effective means of engaging a child in therapeutic activities. Blowing bubbles is another method to increase the child's expiratory phase.

A (The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.)

What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal c. Corn muffin b. Rice cake d. Meat patty

C (Simple dietary modifications are effective in the management of lactose intolerance. Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet. Medications are not typically ordered in the management of lactose intolerance. Providing emotional support to family members is not specific to this medical condition. Diarrhea is a manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel elimination.)

What is the major focus of the therapeutic management for a child with lactose intolerance? a. Compliance with the medication regimen b. Providing emotional support to family members c. Teaching dietary modifications d. Administration of daily normal saline enemas

C (Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes the risk for aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants, but it is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.)

What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? a. Teach parents to position the infant on the left side. b. Reinforce the parents' knowledge of the infant's developmental needs. c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). d. Have the parents keep an accurate record of intake and output.

A (Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing their level of anxiety is often needed before new information can be processed. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness. PTS: 1 DIF: Cognitive Level: Application REF: 1339 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance)

What is the nurse's first action when planning to teach the parents of an infant with a congenital heart defect (CHD)? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.

B (Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.)

What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids b. Corticosteroids c. Antibiotics d. Antidiarrheal medications

More protein will be allowed because of the removal of urea and creatinine by dialysis.

When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching?

C (When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements for upper and lower extremities are compared during an assessment for CHDs. Blood pressure measurements when the child is crying are likely to be elevated; thus the readings will be inaccurate. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance)

When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying

Check the fistula site for a bruit and thrill.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?

D (High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Involvement of mucous membranes and conjunctiva, changes in the extremities, and cardiac involvement are seen. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1354 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

When caring for the child with Kawasaki disease, the nurse should understand that: a. The child's fever is usually responsive to antibiotics within 48 hours. b. The principal area of involvement is the joints. c. Aspirin is contraindicated. d. Therapeutic management includes administration of gamma globulin and aspirin.

D (HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs do not protect against cardiovascular disease. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

When discussing hyperlipidemia with a group of adolescents, the nurse should explain that high levels of what substance are thought to protect against cardiovascular disease? a. Cholesterol b. Triglycerides c. Low-density lipoproteins (LDLs) d. High-density lipoproteins (HDLs).

"Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray."

When teaching a patient scheduled for a cystogram via a cystoscope about the procedure, the nurse tells the patient, ________________

Serum potassium level 6.5 mEq/L

When the nurse is caring for a patient who has been admitted with a severe crushing injury after an industrial accident, which laboratory result will be most important to report to the health care provider?

Drop in urine output

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider?

The patient has metastatic lung cancer.

When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation?

The patient cleans the catheter while taking a bath every day.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

C (Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A -hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A -hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye's syndrome after viral illnesses. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential)

Which action by the school nurse is important in the prevention of rheumatic fever? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts.

Call the health care provider if the ureteral catheter output drops suddenly.

Which action will the nurse include in the plan of care for a patient who has had a ureterolithotomy and has a left ureteral catheter and a urethral catheter in place?

C (Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1322 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

B (Pressure on the bowel from obstruction leads to passage of "currant jelly" stools. Ribbon-like stools are characteristic of Hirschsprung's disease. With intussusception, passage of bloody mucus-coated stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.)

Which description of a stool is characteristic of intussusception? A. Ribbon-like stools B. "Currant jelly" stools C. Hard stools positive for guaiac D. Loose, foul-smelling stools

A (Capoten is an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of aldosterone. Diuril works on the distal tubules. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1332 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

Which drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril)

A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? 1. Call a code blue. 2. Call the health care provider. 3. Check the client status and lead placement. 4. Press the recorder button on the ECG console.

3. Check the client status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission? 1. NPH insulin 2. Regular insulin 3. Chlorpropamide 4. Acarbose (Precose)

3. Chlorpropamide Rationale: Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea. Insulin does not cause or aggravate fluid retention. Acarbose is a miscellaneous oral hypoglycemic agent.

A (Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.

A, C, E (The child with hepatitis should be placed on a well-balanced, low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital, so playtime with other hospitalized children is not scheduled. The child will be on contact isolation for a minimum of 1 week after the onset of jaundice. After that period, the child will be allowed to return to school.)

Which interventions should a nurse implement when caring for a child with hepatitis (Select all that apply)? a. Provide a well-balanced, low-fat diet. b. Schedule playtime in the playroom with other children c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling because the child will not be able to return to school. e. Instruct parents on the importance of good hand washing.

D (The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.

C (Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.)

Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis C vaccine c. Hepatitis B vaccine d. Hepatitis A, B, and C vaccines

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted? 1. Rhonchi 2. Wheezes 3. Crackles in the lung bases 4. Crackles throughout the lung fields

3. Crackles in the lung bases Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client's condition improves, the amount of fluid in the alveoli decreases and may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.) Wheezes and rhonchi are not associated with pulmonary edema.

The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which information? 1. Oxygen assists in calming the client. 2. Oxygen prevents the development of any thrombus formation. 3. Deficient oxygenation to heart cells results in angina pectoris pain. 4. Oxygen dilates the blood vessels, supplying more nutrients to the heart muscle.

3. Deficient oxygenation to heart cells results in angina pectoris pain. Rationale: The pain associated with angina is derived from ischemic myocardial cells. The pain is often associated with activity that places more oxygen demand on heart muscle. Supplemental oxygen helps meet the added demands on the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1. Dyspnea 2. Hacking cough 3. Dependent edema 4. Crackles on lung auscultation

3. Dependent edema Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action? 1. Administer naproxen (Naprosyn). 2. Listen to the client's heart and lungs. 3. Determine if the pain is cardiac in origin. 4. Ask the client about previous cardiac disease.

3. Determine if the pain is cardiac in origin. Rationale: The best initial action is to rule out chest pain of cardiac origin to eliminate a cardiovascular etiology related to the client's complaint. If the pain is left untreated and the pain is caused by myocardial ischemia or infarction (MI), the client could suffer a devastating cardiac injury. Furthermore, the nurse does this because a female presenting with an MI is more likely to display atypical clinical indicators, including fatigue and dyspnea. After instituting measures to rule out a cardiac problem, the nurse completes the client assessment by auscultating the heart and lungs and by reviewing the medical record. After a cardiac problem is ruled out, the nurse can administer an analgesic if prescribed.

The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? 1. Decreased, indicating a decreased risk of coronary artery disease 2. Elevated, but would not present a risk for coronary artery disease 3. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease 4. Normal, indicating adequate blood glucose control with no risk for coronary artery disease

3. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease Rationale: A fasting blood glucose of 200 mg/dL signals the presence of diabetes mellitus. Diabetes mellitus predisposes a client to coronary artery disease. Options 1, 2, and 4 are inaccurate interpretations.

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client? 1. Checking vital signs 2. Reviewing serum electrolytes 3. Evaluating total body fluid 4. Monitoring electrocardiogram

3. Evaluating total body fluid Rationale: Fluid overload can cause complications for the client with heart failure. Therefore, the nurse evaluates the client's fluid balance to forestall activation of harmful compensatory mechanisms and deterioration of other organ systems that increasing total body fluid can cause. This is the nurse's priority because balancing the client's fluid status has the broadest range of potential benefits for the client, including improving oxygenation. The vital signs, serum electrolytes, and electrocardiogram are important assessments, yet remain secondary in importance to fluid status because they are items that are affected by fluid balance.

A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time? 1. Tell the client that his fears are not rational. 2. Tell the client that his life has not changed. 3. Explore the specific concerns with the client. 4. Tell the client to talk it out with the significant other.

3. Explore the specific concerns with the client. Rationale: The therapeutic action by the nurse is one that gathers more data. This then allows the nurse to formulate the appropriate response. Each of the incorrect options is nontherapeutic because they place the client's feelings on hold and do not address them.

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms? 1. Skin scratches 2. Vaginal itching 3. Fever and sore throat 4. Burning on urination

3. Fever and sore throat Rationale: Rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. The other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively.

The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record? 1. Excessive oral secretions 2. Bowel sounds heard over the chest 3. Hiccuping and spitting up after a meal 4. Coughing, wheezing, and short periods of apnea

3. Hiccuping and spitting up after a meal Clinical manifestations of all types of gastroesophageal reflux include vomiting (spitting up) after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep. Option 1 is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Option 2 is a clinical manifestation of congenital diaphragmatic hernia. Option 4 is a clinical manifestation of hiatal hernia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Data Collection Content Area: Child Health: Gastrointestinal Strategy(ies): Subject Priority Concepts: Fluid and Electrolyte Balance, Gas Exchange

15. The nurse is caring for a 3-month-old male who is being evaluated for possible Hirschsprung disease. His parents call the nurse and state that his diaper contains a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which of the following should be the nurse's next action? 1. Reassure the parents that this is an expected finding and not uncommon. 2. Call a code for a potential cardiac arrest, and stay with the infant. 3. Immediately obtain all vital signs with a quick head-to-toe assessment. 4. Obtain a stool sample for occult blood.

3. Immediately obtain all vital signs with a quick head-to-toe assessment. All vital signs need to be evaluated because the child with enterocolitis can quickly progress to a state of shock A quick head-to-toe assessment will allow the nurse to evaluate the child's circulatory system.

A 7-month-old has a low-grade fever, nasal congestion, and a mild cough. What should the nursing care management of this child include? 1. Maintaining strict bedrest. 2. Avoiding contact with family members. 3. Instilling saline nose drops and bulb suctioning. 4. Keeping the head of the bed flat.

3. Instilling saline nose drops and bulb suctioning. Infants are nose breathers and often have increased difficulty when they are congested. Nasal saline drops and gentle suctioning with a bulb syringe

The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities? 1. Deep breathing and coughing 2. Repositioning self from side to side 3. Isometric exercises of the arms and legs 4. Ankle circles, plantar, and dorsiflexion exercises

3. Isometric exercises of the arms and legs Rationale: The client with myocardial infarction should avoid activities that tense the muscles, such as isometric exercises. These increase intra-abdominal and intrathoracic pressures and can decrease the cardiac output. They also can trigger vagal stimulation, causing bradycardia. The exercises in options 1, 2, and 4 are acceptable.

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? 1. Having the client void before surgery 2. Completing a preoperative checklist 3. Marking the location of the pedal pulses on the right leg 4. Checking the results of any baseline coagulation studies

3. Marking the location of the pedal pulses on the right leg Rationale: A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.

25. The nurse is caring for a 5-year-old who has just returned from having an appendectomy. Which of the following is the optimal way to manage pain? 1. Intravenous morphine as needed. 2. Liquid Tylenol with codeine as needed. 3. Morphine administered through a PCA pump. 4. Intramuscular morphine as needed.

3. Morphine administered through a PCA pump. Morphine administered through a PCA pump offers the child control over managing pain. The PCA pump also has the benefit of offering a basal rate as well as an as-needed rate for optimal pain management.

Which information will be most helpful in teaching parents about the primary prevention of foreign body aspiration? 1. Signs and symptoms of foreign body aspiration. 2. Therapeutic management of foreign body aspiration. 3. Most common objects that toddlers aspirate. 4. Risks associated with foreign body aspiration.

3. Most common objects that toddlers aspirate. Teaching parents the most common objects aspirated by toddlers will help them the most. Parents can avoid having those items in the household or in locations where toddlers may have access to them.

Stool from an ileostomy will be: 1. Soft and semi-formed 2. Often only once per day as per prior to the ostomy 3. Mostly liquid 4. Low in electrolytes and water

3. Mostly liquid

How will a child with respiratory distress and stridor and who is diagnosed with RSV be treated? 1. Intravenous antibiotics. 2. Intravenous steroids. 3. Nebulized racemic epinephrine. 4. Alternating doses of Tylenol and Motrin.

3. Nebulized racemic epinephrine. Racemic epinephrine promotes mucosal vasoconstriction.

You are prepping your patient for a KUB. What should you prepare for? 1. Enemas to clear 2. NPO after MN 3. Nothing special 4. Pt will need to drink prep

3. Nothing special

The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? 1. Pain with diaphoresis 2. Discomfort in one digit 3. Numbness and tingling in the legs 4. Cramping in the foot while resting

3. Numbness and tingling in the legs Rationale: Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. Options 1, 2, and 4 are not complications of this disorder. The finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position to place this infant at this time is which? 1. A flat position 2. A prone position 3. On his or her left side 4. On his or her right side

3. On his or her left side After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case, it is best to place the infant on the left side. Additionally, the flat or prone position can result in aspiration if the infant vomits. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Child Health: Gastrointestinal Strategy(ies): Strategic Words Priority Concepts: Clinical Judgment, Safety

The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside? 1. Bedside commode 2. Rolling shower chair 3. Oxygen tubing and flowmeter 4. Twelve-lead electrocardiogram (ECG) machine

3. Oxygen tubing and flowmeter Rationale: CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. Providing oxygen to the client is important to help decrease pain and prevent its recurrence. A bedside commode and ECG machine may be helpful but are not the priority. A rolling shower chair has no value for this client because the client should be able to walk and shower if pain free and an activity prescription allows it.

A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way? 1. Result in hypoglycemia 2. Give the client insomnia 3. Precipitate rebound hypertension 4. Cause enhanced side effects of other prescribed medications

3. Precipitate rebound hypertension Rationale: Beta-adrenergic blocking agents should be tapered slowly. This will avoid abrupt withdrawal syndrome, characterized by headache, malaise, palpitations, tremors, sweating, rebound hypertension, dysrhythmias, and possibly myocardial infarction (in clients with cardiac disorders, including angina pectoris). Options 1, 2, and 4 are incorrect.

An infant is not sleeping well, crying frequently, has yellow drainage from the ear, and is diagnosed with an ear infection. Which nursing objective is the priority for the family? 1. Educating the parents about signs and symptoms of an ear infection. 2. Providing emotional support for the parents. 3. Providing pain relief for the child. 4. Promoting the flow of drainage from the ear.

3. Providing pain relief for the child. Providing pain relief for the infant is essential. With pain relief, the child will likely stop crying and rest better.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction

3. Pulmonary embolism Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

44. The nurse is caring for an infant with pyloric stenosis. The parents ask if any future children will likely have pyloric stenosis. Select the nurse's best response. 1. "You seem worried; would you like to discuss your concerns?" 2. "It is very rare for a family to have more than one child with pyloric stenosis." 3. "Pyloric stenosis can run in families. It is more common among males." 4. "Although there can be a genetic link, it is very unusual for girls to have pyloric stenosis."

3. Pyloric stenosis can run in families, and it is more common in males.

The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? 1. Mental status 2. Urinary output 3. Respirations and blood pressure 4. Temperature and blood pressure

3. Respirations and blood pressure Rationale: Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client who experienced an MI. Although monitoring mental status is a component of the nurse's assessment, it is not the priority following administration of morphine sulfate. The nurse should monitor the client's respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature is also not associated with the use of this medication.

23. The nurse is caring for an 8-year-old who has just returned to the pediatric unit after an appendectomy for a ruptured appendix. Which of the following is the best position for the child? 1. Semi-Fowler. 2. Prone. 3. Right side-lying. 4. Left side-lying..

3. Right side-lying. The right side-lying position promotes comfort and allows the peritoneal cavity to drain

A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia? 1. Supine 2. Left lateral 3. Semi-Fowler's 4. Trendelenburg's

3. Semi-Fowler's Rationale: Coolness, pallor, and tachycardia are consistent with clinical indicators of hypoxia related to inadequate cardiac output. To reduce the myocardial workload, improve cardiac output, and promote tissue oxygenation, the nurse positions the client in the semi-Fowler's position to maintain perfusion to vital organs and promote chest expansion (option 3) so long as the client's neurological status is stable. The supine position removes the strain on the heart of pumping blood against gravity into the cerebral vasculature effectively; however, a flat position can lead to excessive preload and increase the cardiac workload (option 1). Left-lateral position could be satisfactory (option 2), but until the client is stable and unless the client is at risk for aspiration, semi-Fowler's position is a better choice. Trendelenburg's position is used when the client experiences profound hypotension or shock (option 4).

The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply. 1. Lying supine 2. Right side-lying 3. Sitting up and leaning forward 4. Semi-Fowler's with knees bent 5. Head of bed elevated to 45 degrees

3. Sitting up and leaning forward 5. Head of bed elevated to 45 degrees Rationale: Acute pericarditis refers to inflammation of the pericardial sac. A common symptom is chest pain. Chest pain is often relieved when the client sits up and leans forward or with the head of bed elevated to 45 degrees. Lying supine makes the pain worse. Right side-lying and semi-Fowler's with knees bent does not relieve the chest pain associated with acute pericarditis.

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 1. Viral infection 2. Yeast infection 3. Streptococcal infection 4. Staphylococcal infection

3. Streptococcal infection Rationale: Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis. Options 1, 2, and 4 are incorrect.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? 1. Legs are unsightly in appearance and distress the client. 2. The client complains of aching and feelings of heaviness in the legs. 3. The client complains of leg edema, and skin breakdown has started. 4. The health care provider finds that the legs become distended when the tourniquet is released during the Trendelenburg's test.

3. The client complains of leg edema, and skin breakdown has started. Rationale: Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

2. The mother of a newborn asks the nurse why she has to nurse so frequently. The nurse replies using which of the following principles? 1. Formula tends to be more calorically dense, and formula-fed babies require fewer feedings than breastfed babies. 2. The newborn's stomach capacity is small, and peristalsis is slow. 3. The newborn's stomach capacity is small, and peristalsis is more rapid than in older children. 4. Breastfed babies tend to take longer to complete a feeding than formula-fed babies.

3. The newborn's stomach capacity is small, and peristalsis is more rapid than in older children. The small-stomach capacity and rapid movement of fluid through the digestive system account for the need for small frequent feedings.

The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? 1. The client is not experiencing nausea or vomiting. 2. The pain is described as substernal and radiating to the left arm. 3. The pain has not been unrelieved by rest and nitroglycerin tablets. 4. The client says the pain began while trying to open a stuck dresser drawer.

3. The pain has not been unrelieved by rest and nitroglycerin tablets. Rationale: The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.

A client, who is 36 hours post-myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made? 1. The skin is cool but slightly diaphoretic. 2. Dyspnea is noted only at the end of the exercise. 3. The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute. 4. The preactivity blood pressure (BP) is 140/84 mm Hg; the postactivity BP is 110/72 mm Hg.

3. The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute. Rationale: The nurse checks vital signs and the level of fatigue with each activity. The client is not tolerating the activity if systolic BP drops more than 20 mm Hg, pulse rate increases more than 20 beats per minute, or if the client experiences dyspnea or chest pain. In addition, a significant drop in BP can indicate orthostatic hypotension, which is an abnormal condition. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise.

For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? 1. Elevating the legs when in bed 2. Sleeping in the supine position 3. Using a bedside commode for stools 4. Seasoning beef with a meat tenderizer

3. Using a bedside commode for stools Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client's legs would increase venous return to the heart and result in an increase in cardiac workload. The supine position can increase respiratory effort and decrease oxygenation, which increases cardiac workload. Meat tenderizers are high in sodium. Sodium contributes to hypertension, which increases cardiac workload.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the health care provider to write a prescription for the client to remain on bed rest. In which position should the bed be positioned? 1. In the high-Fowler's position 2. With the head of bed elevated at least 60 degrees 3. With the head of bed elevated no more than 30 degrees 4. With the foot of bed elevated as much as tolerated by the client

3. With the head of bed elevated no more than 30 degrees Rationale: Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? 1. In semi-Fowler's position 2. With the head of the bed elevated 45 degrees 3. With the head of the bed elevated no more than 15 degrees 4. With the foot of the bed elevated as much as tolerated by the client

3. With the head of the bed elevated no more than 15 degrees Rationale: Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 4 to 6 hours. The client may turn from side to side. The head of the bed is not elevated more than 30 degrees to prevent kinking of the blood vessel at the groin and possible arterial occlusion.

The parents of a 6-year-old who has a new diagnosis of asthma ask the nurse what to do to make their home a more allergy-free environment. Which is the nurse's best response? 1. "Use a humidifier in your child's room." 2. "Have your carpet cleaned chemically once a month." 3. "Wash household pets weekly." 4. "Avoid purchasing upholstered furniture."

4. "Avoid purchasing upholstered furniture." Leather furniture is recommended rather than upholstered furniture. Upholstered furniture can harbor large amounts of dust, whereas leather furniture may be wiped off regularly with a damp cloth.

The parent of a child with croup tells the nurse that her other child just had croup and it cleared up in a couple of days without intervention. She asks the nurse why this child is exhibiting worse symptoms and needs to be hospitalized. Which is the nurse's best response? 1. "Some children just react differently to viruses. It is best to treat each child as an individual." 2. "Younger children have wider airways that make it easier for bacteria to enter and colonize." 3. "Younger children have short and wide eustachian tubes, making them more susceptible to respiratory infections." 4. "Children younger than 3 years usually exhibit worse symptoms because their immune systems are not as developed."

4. "Children younger than 3 years usually exhibit worse symptoms because their immune systems are not as developed." Younger children have less developed immune systems and usually exhibit worse symptoms than older children.

A mother is crying and tells the nurse that she should have brought her son in yesterday when he said his throat was sore. Which is the nurse's best response to this parent whose child is diagnosed with epiglottitis and is in severe distress and in need of intubation? 1. "Children this age rarely get epiglottitis; you should not blame yourself." 2. "It is always better to have your child evaluated at the first sign of illness rather than wait until symptoms worsen." 3. "Epiglottitis is slowly progressive, so early intervention may have decreased the extent of your son's symptoms." 4. "Epiglottitis is rapidly progressive; you could not have predicted his symptoms would worsen so quickly."

4. "Epiglottitis is rapidly progressive; you could not have predicted his symptoms would worsen so quickly." Epiglottitis is rapidly progressive and cannot be predicted.

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? 1. "I am considering cutting my workload." 2. "I need to cut down on cigarette smoking." 3. "I am so relieved that my heart is repaired." 4. "I need to adhere to my dietary restrictions."

4. "I need to adhere to my dietary restrictions." Rationale: Following the angioplasty, the client needs to be instructed about specific dietary restrictions that must be followed. Following the recommended dietary and lifestyle changes helps prevent further atherosclerosis. Abrupt closure of the artery can occur if the recommended dietary and lifestyle changes are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.

A child is complaining of throat pain. Which statement by the mother indicates that she needs more education regarding the care and treatment of her daughter's pharyngitis? 1. "I will have my daughter gargle with salt water three times a day." 2. "I will offer my daughter ice chips several times a day." 3. "I will give my daughter Tylenol every 4 to 6 hours as needed." 4. "I will ask the nurse practitioner for some amoxicillin."

4. "I will ask the nurse practitioner for some amoxicillin." Pharyngitis is a self-limiting viral illness that does not require antibiotic therapy. Pharyngitis should be treated with rest and comfort measures, including Tylenol, throat sprays, cold liquids, and Popsicles.

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? 1. "Since the damage has already been done, it will be all right to cut down a little at a time." 2. "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 3. "If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale: The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is comparable to that of a person who never smoked. Therefore, options 1, 2, and 3 are incorrect.

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere, anytime."

4. "The best thing about this is that I can use it anywhere, anytime." Rationale: Guided imagery involves the client's creation of an image in the mind, concentrating on the image, and gradually become less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it.

The nurse is reviewing discharge instructions with the parents of a child who had a tonsillectomy 24 hours ago. The parents tell the nurse that the child is a big eater, and they want to know what foods to give the child for the next 24 hours. What is the nurse's best response? 1. "The child's diet should not be restricted at all." 2. "The child's diet should be restricted to clear liquids." 3. "The child's diet should be restricted to ice cream and cold liquids." 4. "The child's diet should be restricted to soft foods."

4. "The child's diet should be restricted to soft foods." Soft foods are recommended to limit the child's pain and to decrease the risk for bleeding.

16. A 3-year-old returns to the pediatric clinic after having had MCNS. His parents ask the nurse how to prevent the child from having it again. What is the nurse's best response? 1. "It is very rare for a child to have a relapse after having fully recovered." 2. "Unfortunately, many children have cycles of relapses, and there is very little that can be done to prevent it." 3. "Your child is much less likely to get sick again if sodium is avoided in his diet." 4. "Try to keep your child away from sick children because relapses have been associated with infectious illnesses."

4. "Try to keep your child away from sick children because relapses have been associated with infectious illnesses." Exposure to infectious illness has been linked to the relapse of nephrotic syndrome.

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first? 1. "Do you exercise regularly?" 2. "Would you consider losing weight?" 3. "Is there a history of diabetes mellitus in your family?" 4. "When was the last time you had your blood pressure checked?"

4. "When was the last time you had your blood pressure checked? Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.

What is the most important piece of information that the nurse must ask the parent of a child in status asthmaticus? 1. "What time did your child eat last?" 2. "Has your child been exposed to any of the usual asthma triggers?" 3. "When was your child last admitted to the hospital for asthma?" 4. "When was your child's last dose of medication?"

4. "When was your child's last dose of medication?" The nurse needs to know what medication the child had last and when the child took it in order to know how to begin treatment for the current asthmatic condition.

6. A 2-year-old has just been diagnosed with cystic fibrosis (CF). The parents ask the nurse what early respiratory symptoms they should expect to see in their child. Which is the nurse's best response? 1. "You can expect your child to develop a barrel-shaped chest." 2. "You can expect your child to develop a chronic productive cough." 3. "You can expect your child to develop bronchiectasis." 4. "You can expect your child to develop wheezing respirations."

4. "You can expect your child to develop wheezing respirations." Wheezing respirations and a dry, nonproductive cough are common early symptoms in CF.

59. The parent of a 9-month-old calls the ER because his child is choking on a marble. The parent asks how to help his child while awaiting Emergency Medical Services. Which is the nurse's best response? 1. "You should administer five abdominal thrusts followed by five back blows." 2. "You should try to retrieve the object by inserting your finger in your child's mouth." 3. "You should perform the Heimlich maneuver." 4. "You should administer five back blows followed by five chest thrusts."

4. "You should administer five back blows followed by five chest thrusts." The current recommendation for infants younger than 1 year is to administer five back blows followed by five chest thrusts.

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? 1. Midsternum equal with the nipple line 2. At the midaxillary line on the left side of the chest 3. At the midline of the chest just below the xiphoid process 4. At the midclavicular line at the fifth left intercostal space

4. At the midclavicular line at the fifth left intercostal space Rationale: The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.

The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted? 1. Mild dyspnea after walking 10 feet 2. Minimal chest pain rated 1 on a 1-to-10 pain scale 3. Pulse rate that increases from 68 to 94 beats per minute 4. Blood pressure that increases from 114/82 to 118/86 mm Hg

4. Blood pressure that increases from 114/82 to 118/86 mm Hg Rationale: General indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats per minute, and a blood pressure change of less than 10 mm Hg.

54. The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? 1. Eggs, bacon, rye toast, and lactose-free milk. 2. Pancakes, orange juice, and sausage links. 3. Oat cereal, breakfast pastry, and nonfat skim milk. 4. Cheese, banana slices, rice cakes, and whole milk.

4. Cheese, banana slices, rice cakes, and whole milk do not contain gluten.

When assessing the clients abdomen the student nurse hears high pitched sound, low gurgling sounds, and loud rubs. How can she begin to determine which sounds are lung sounds and which come from peristalsis? 1. Listen only below the umbilicus for bowel tones 2. Listen while holding your breath so you don't confuse your own sounds with that of the client 3. Palpate first so the abdominal sounds will be louder 4. Correlate the repeated sounds with the respiratory cycle knowing they will stop if the client holds his breath

4. Correlate the repeated sounds with the respiratory cycle knowing they will stop if the client holds his breath

The nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which manifestation led the mother to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. The regurgitation of feedings 4. Foul-smelling, ribbon-like stools

4. Foul-smelling, ribbon-like stools Chronic constipation that begins during the first month of life and that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain and distention, and failure to thrive are also signs and symptoms. This disorder results in a decrease in passage of stool, so diarrhea would not be a presenting manifestation. Hirschsprung's disease affects the colon, so regurgitation and vomiting most often associated with esophageal and stomach pathology would not be presenting manifestations. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process: Data Collection Content Area: Child Health: Gastrointestinal Strategy(ies): Subject Priority Concepts: Elimination, Nutrition

The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal? 1. Sausage, pancakes, and toast 2. Broccoli, buttered rice, and grilled chicken 3. Hamburger, baked apples, and avocado salad 4. Fresh strawberries, steamed vegetables, and baked fish

4. Fresh strawberries, steamed vegetables, and baked fish Rationale: Diets high in saturated fats raise the serum lipid level, which, in turn, raises the blood cholesterol. Over time, high blood cholesterol levels lead to the development of atherosclerosis and diseases such as coronary artery disease. A diet that is low in saturated fats is helpful in reducing the progression of atherosclerosis. Meats and dairy products tend to be higher in fat than other food groups.

Which intervention is most appropriate to teach the mother of a child diagnosed with a URI and a dry hacking cough that prevents him from sleeping? 1. Give cough suppressants at night. 2. Give an expectorant every 4 hours. 3. Give cold and flu medication every 8 hours. 4. Give 1/2 teaspoon of honey four to five times per day.

4. Give 1/2 teaspoon of honey four to five times per day. Warm fluids, humidification, and honey are best treatments for a URI.

The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next? 1. Do a repeat 12-lead ECG. 2. Wait to see whether the pain resolves. 3. Report the episode of chest pain to the health care provider. 4. Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions.

4. Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions. Rationale: After completing the stat ECG, the nurse should administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. The nurse should not wait to see whether pain resolves on its own but should determine whether the pain is relieved with nitroglycerin. The nurse should do a repeat ECG if it is prescribed. The nurse should report the episode of pain to the health care provider but should administer the nitroglycerin before doing so.

The nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse should plan to maintain bed rest for this client in which position? 1. High-Fowler's position 2. Lateral (side-lying) position 3. Head elevation of 45 degrees 4. Head elevation of no more than 30 degrees

4. Head elevation of no more than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. The client may turn from side to side. The client is placed in the supine position and the head of the bed is not elevated to more than 30 degrees to keep the affected leg straight at the groin and prevent arterial occlusion. Bathroom privileges are not allowed during the immediate postcatheterization period. For the high-Fowler's position, the head of the bed is elevated 90 degrees.

21. The nurse is caring for a 10-year-old who is being evaluated for possible appendicitis. The child has been complaining of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, finds the pain relieved, and calls the nurse. Which of the following should be the nurse's next action? 1. Cancel the ultrasound, and obtain an order for oral Zofran. 2. Cancel the ultrasound, and prepare to administer an intravenous bolus. 3. Prepare for the probable discharge of the patient. 4. Immediately notify the physician of the child's status.

4. Immediately notify the physician of the child's status. The physician should be notified immediately, as a sudden change or loss of pain often indicates a perforated appendix

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? 1. Exposure to heat 2. Being in a relaxed environment 3. Prolonged episodes of inactivity 4. Ingestion of coffee or chocolate

4. Ingestion of coffee or chocolate Rationale: Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? 1. Tell the client that this is not allowed. 2. Tell the family member not to take the client outdoors. 3. Give the client a cup of hot coffee before going outside. 4. Instruct the family member to dress the client warmly before going outside.

4. Instruct the family member to dress the client warmly before going outside. Rationale: The nurse should meet both the physiological and psychosocial needs of the client in a holistic manner by asking the family member to be sure that the client is dressed warmly before going outside. Option 4 is correct because dressing the client warmly will decrease the chance of vasoconstriction, which may lead to an angina attack. Options 1 and 2 ignore the psychosocial needs. Option 3 is detrimental to physiological needs because, in addition to the cold weather, caffeine places an additional burden on the heart.

17. The nurse is caring for a 2-month-old infant diagnosed with GER. Which of the following should the nurse include in the plan of care to decrease the incidence of symptoms of GER? 1. Place the infant in an infant seat immediately after feedings. 2. Place the infant in the prone position immediately after feeding to decrease the risk of aspiration. 3. Encourage the parents not to worry because most infants outgrow GER within the first year of life. 4. Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding.

4. Keeping the infant in an upright position is the best way to decrease the symptoms of GER. The infant can also be placed in the supine position with the head of the crib elevated. A harness can be used to keep the child from sliding down.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? 1. Tea 2. Cola 3. Coffee 4. Lemonade

4. Lemonade Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

Mrs. G states she has been irregular and has been taking ex-lax every night to make sure she has a regular BM. The correct nursing diagnosis is: 1. Constipation 2. Paralytic ileus 3. Diarrhea 4. Perceived constipation

4. Perceived constipation

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 1. Provide the client with a walker. 2. Remove the telemetry equipment. 3. Encourage the client to cough and deep breathe. 4. Premedicate the client with an analgesic before ambulating.

4. Premedicate the client with an analgesic before ambulating. Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

49. A nurse working in an emergency room of a large pediatric hospital receives a transfer call from a reporting nurse at a local community hospital. The nurse will soon receive a 4-month-old who has been diagnosed with an intussusception. The infant is described as very lethargic with the following vital signs, T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant's abdomen is very rigid. Which of the following is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confirm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fluids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.

4. Prepare to get the infant ready for immediate surgical correction. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse's top priority.

The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? 1. Prinzmetal's angina is effectively managed by beta-blocking agents. 2. Prinzmetal's angina improves with a low-sodium, high-potassium diet. 3. Prinzmetal's angina has the same risk factors as stable and unstable angina. 4. Prinzmetal's angina is generally treated with calcium channel blocking agents.

4. Prinzmetal's angina is generally treated with calcium channel blocking agents. Rationale: Prinzmetal's angina results from spasm of the coronary arteries and is generally treated with calcium channel blocking agents. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Beta-blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not specifically indicated although a healthy diet consuming foods low in fat and sodium is advocated in cardiac disease.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 1. Intake and output 2. Height and weight 3. Peripheral pulse rates 4. Prior reaction to contrast media

4. Prior reaction to contrast media Rationale: This procedure requires a signed informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. Although intake and output, height and weight, and presence of peripheral pulses may be components of data collection, they are not the most critical items.

The nurse reviews the record of a 1-year-old child seen in the clinic and notes that the health care provider has documented a diagnosis of celiac crisis. Which symptom should the nurse expect to note in this condition? 1. Anorexia 2. Joint pain 3. Constipation 4. Profuse, watery diarrhea

4. Profuse, watery diarrhea Clinical signs/symptoms associated with celiac crisis include profuse, watery diarrhea and vomiting that quickly lead to severe dehydration and *metabolic acidosis.* The cause of the crisis is usually infection or hidden sources of gluten. The child may require intravenous fluids to correct fluid and acid-base imbalances, albumin to treat shock, and corticosteroids to decrease severe mucosal inflammation. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process: Data Collection Content Area: Child Health: Gastrointestinal Strategy(ies): Subject Priority Concepts: Elimination, Fluid and Electrolyte Balance

When preparing a client for a pericardiocentesis, which position does the nurse place the client in? 1. Supine with slight lowering of the head 2. Lying on the right side with a pillow under the head 3. Lying on the left side with a pillow under the chest wall 4. Supine with the head of bed elevated at a 45- to 60-degree angle

4. Supine with the head of bed elevated at a 45- to 60-degree angle Rationale: The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac. The remaining options are incorrect positions for this procedure.

The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client? 1. Increase fluids to 3000 mL per day to promote renal perfusion. 2. Consume 1 to 2 oz of liquor each night to promote vasodilation. 3. Try to engage in vigorous activity to strengthen cardiac reserve. 4. Take in adequate daily fiber to prevent straining during a bowel movement.

4. Take in adequate daily fiber to prevent straining during a bowel movement. Rationale: Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluid and electrolyte balance. Increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.

39. The nurse is in the room while a mother of a newborn is feeding her infant for the first time. The baby immediately begins coughing and choking. The nurse notes that the baby is extremely cyanotic. Which of the following should be the nurse's immediate action? 1. Call the physician, and inform the physician of the situation. 2. Have the mother stop feeding the infant, and observe to see if the choking episode resolves on its own. 3. Immediately determine the infant's oxygen saturation, and have the mother stop feeding the infant. 4. Take the infant from the mother, and administer blow-by oxygen while obtaining the infant's oxygen saturation.

4. Take the infant from the mother, and administer blow-by oxygen while obtaining the infant's oxygen saturation. The infant should be taken from the mother and placed in the crib where the nurse can assess the baby. Oxygen should be administered immediately, and vital signs should be obtained.

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client? 1. Reports the client to the police for illegal drug use 2. Explains to the client the damage that cocaine does to the heart 3. Tells the client it is imperative to stop before myocardial infarction occurs 4. Teaches about the effects of cocaine on the heart and offers referral for further help

4. Teaches about the effects of cocaine on the heart and offers referral for further help Rationale: To provide the most holistic care, the nurse should meet the information needs of the client about the effects of cocaine on the heart and offer referral for further help with this possible addiction. Option 1 is partially correct but does not meet the holistic needs of the client. Option 2 is not indicated and breaches the client's right to confidentiality. Option 3 is incorrect because it "preaches" to the client.

A school-age child is admitted to the hospital for a tonsillectomy. During the nurse's post-operative assessment, the child's parent tells the nurse that the child is in pain. Which of the following observations would be of most concern to the nurse? 1. The child's heart rate and blood pressure are elevated. 2. The child complains of having a sore throat. 3. The child is refusing to eat solid foods. 4. The child is swallowing excessively.

4. The child is swallowing excessively. Excessive swallowing is a sign that the child is swallowing blood. This should be considered a medical emergency, and the physician should be contacted immediately. The child is likely bleeding and will need to return to surgery.

Which would the nurse explain to parents about the inheritance of cystic fibrosis? 1. CF is an autosomal-dominant trait passed on from the child's mother. 2. CF is an autosomal-dominant trait passed on from the child's father. 3. The child of parents who are both carriers of the gene for CF has a 50% chance of acquiring CF. 4. The child of a mother who has CF and a father who is a carrier of the gene for CF has a 50% chance of acquiring CF.

4. The child of a mother who has CF and a father who is a carrier of the gene for CF has a 50% chance of acquiring CF. If the child is born to a parent with CF and the other parent is a carrier, the child has a 50% chance of acquiring the disease and a 50% chance of being a carrier of the disease.

A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of which diagnosis? a. Bronchitis b. Bronchiolitis c. Viral-induced asthma d. Acute spasmodic laryngitis

A Bronchitis is characterized by these symptoms and occurs in children older than 6 years. Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years.

In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? a. Diet should be high in carbohydrates and protein. b. Diet should be high in easily digested carbohydrates and fats. c. Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed.

A Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.

B (Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.)

A 4-month-old infant has gastroesophageal reflux disease (GERD) but is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

organ meats and sardines.

A patient's renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating __________________

check which medications the patient is currently taking.

A patient's urine dipstick indicates a small amount of protein in the urine. The next action by the nurse should be to ______________

C (Although an echocardiogram is noninvasive, painless, and associated with no known side effects, it can be stressful for children. The child must lie quietly in the standard echocardiographic positions; crying, nursing, being held, or sitting up often leads to diagnostic errors or omissions. Therefore, infants and young children may need a mild sedative; older children benefit from psychologic preparation for the test. The distraction of a video or movie is often helpful. PTS: 1 DIF: Cognitive Level: Application REF: 1352 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response? a. "You will be able to hold your child during the procedure." b. "Your child can be active during the procedure, but can't sit in your lap." c. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure." d. "The procedure is invasive so your child will be restrained during the echocardiogram."

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply. 1. Administer a Fleet enema. 2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications 6. Place a heating pad on the abdomen to decrease pain.

ANS 2,3,4,5 During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix and resultant peritonitis. Intravenous fluids would be started, and the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Child Health: Gastrointestinal Strategy(ies): Subject Priority Concepts: Inflammation, Safety

C (Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprung's disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.)

Acute diarrhea is often caused by: a. Hirschsprung's disease. b. Hypothyroidism. c. Antibiotic therapy. d. Meconium ileus.

The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also complains of a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100 degrees Fahrenheit. The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have a) Rheumatic fever b) A urinary tract infection c) Acute glomerulonephritis d) Lipoid nephrosis (idiopathic nephrotic syndrome)

Acute glomerulonephritis Correct Explanation: Acute glomerulonephritis is a condition that appears to be an allergic reaction to specific infections, most often group A beta-hemolytic streptococcal infections such as rheumatic fever. Presenting symptoms appear one to three weeks after the onset of a streptococcal infection such as strep throat, otitis media, tonsillitis, or impetigo. Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103 to 104 degrees Fahrenheit at the onset but decreases in a few days to about 100 degrees Fahrenheit. Slight headache and malaise are usual, and vomiting may occur.

B (The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell; cardiopulmonary resuscitation is not necessary, and death is unlikely. PTS: 1 DIF: Cognitive Level: Application REF: 1337 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to: a. Assess for neurologic defects. b. Place the child in the knee-chest position. c. Begin cardiopulmonary resuscitation. d. Prepare the family for imminent death.

Insert a urinary retention catheter.

An 88-year-old with benign prostatic hyperplasia (BPH) has a markedly distended bladder and is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?

B (Identification of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are nonpharmacologic treatments for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. -Adrenergic receptor blockers are indicated in the treatment of primary hypertension. PTS: 1 DIF: Cognitive Level: Application REF: 1350 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension initially involves: a. Weight control and diet. b. Treating the underlying disease. c. Administration of digoxin. d. Administration of -adrenergic receptor blockers.

A (The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.)

An important nursing consideration in the care of a child with celiac disease is to: a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and Standard Precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms.

C (It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing intravenous line. It is not a pain-free procedure. A sharp, momentary pain is felt, and this should not be misrepresented to the child. A petroleum gauze/airtight dressing is needed. Little or no drainage should be found on removal. PTS: 1 DIF: Cognitive Level: Analysis REF: 1342 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity)

An important nursing consideration when chest tubes will be removed from a child is to: a. Explain that it is not painful. b. Explain that only a Band-Aid will be needed. c. Administer analgesics before the procedure. d. Expect bright red drainage for several hours after removal.

C (These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.)

An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of: a. Overhydration. b. Sodium excess. c. Dehydration. d. Calcium excess.

D (Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.)

An infant with pyloric stenosis experiences excessive vomiting that can result in: a. Hyperchloremia. b. Metabolic acidosis. c. Hypernatremia. d. Metabolic alkalosis.

63. The client is prescribed continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged I.V. pole. She then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow? 1. Evaluating patency of the drainage lumen 2. Counter-balancing the I.V. pole 3. Attaching the infusion set to an infusion pump 4. Collecting a urine specimen before beginning irrigation

Answer 1 RATIONALES: The nurse should evaluate patency of the drainage tubing before leaving the client's room. If the lumen is obstructed, the solution infuses into the bladder but isn't eliminated through the drainage tubing, a situation that may cause client injury. Balancing the pole is important; however, the nurse would have had to address this issue immediately after hanging the 2 L bag. Using an I.V. pump isn't necessary for continuous bladder irrigation. Unless specifically ordered, obtaining a urine specimen before beginning continuous bladder irrigation isn't necessary.

96. A client reports experiencing vulvar pruritus. Which assessment factor may indicate that the client has an infection caused by Candida albicans? 1. Cottage cheese-like discharge 2. Yellow-green discharge 3. Gray-white discharge 4. Discharge with a fishy odor

Answer 1 RATIONALES: The symptoms of C. albicans include itching and a scant white discharge that has the consistency of cottage cheese. Yellow-green discharge is a sign of Trichomonas vaginalis. Gray-white discharge and a fishy odor are signs of Gardnerella vaginal

87. A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? 1. Acute pain 2. Risk for infection 3. Impaired urinary elimination 4. Imbalanced nutrition: Less than body requirements

Answer 1 RATIONALES: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.

84. A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include: 1. continuous inflow and outflow of irrigation solution. 2. intermittent inflow and continuous outflow of irrigation solution. 3. continuous inflow and intermittent outflow of irrigation solution. 4. intermittent flow of irrigation solution and prevention of hemorrhage.

Answer 1 RATIONALES: When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.

10. The nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which of the following? 1. Trousseau's sign 2. Cardiac arrhythmias 3. Constipation 4. Decreased clotting time 5. Drowsiness and lethargy 6. Fractures

Answer 1,2,6 RATIONALES: Hypocalcemia is a calcium deficit that causes nerve fiber irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability. The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures.

5. A client returns to the medical-surgical unit after coronary artery bypass graft surgery, which was complicated by prolonged cardiopulmonary bypass and hypotension. After 3 hours in the unit, the client's condition stabilizes. However, the urine output has decreased despite adequate filling pressures. The nurse expects the physician to add which drug, at which flow rate, to the client's regimen? 1. Dopamine (Intropin), 3 mcg/kg/min 2. Epinephrine, 2 mcg/kg/min 3. Dopamine (Intropin), 8 mcg/kg/min 4. Epinephrine, 4 mcg/kg/min

Answer 1: Answer 1: RATIONALES: This client is at high risk for acute prerenal failure secondary to decreased renal perfusion during surgery. To dilate the renal arteries and help prevent renal shutdown, the physician is likely to prescribe dopamine at a low flow rate (2 to 5 mcg/kg/min). Although this drug has mixed dopaminergic and beta activity when given at 5 to 10 mcg/kg/min, the client is stabilized and thus doesn't need the beta effects from the higher flow rate — or the sympathomimetic effects of epinephrine. The dopaminergic effects of dopamine increase renal perfusion, contractility, and vasodilation. Stimulation of beta receptors causes beta effects — namely, increases in the heart rate, myocardial contraction force, and cardiac conduction

51. After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir). Which statement by the client indicates a need for further teaching? 1. "I'll have to wear an external collection pouch for the rest of my life." 2. "I should eat foods from all the food groups." 3. "I'll need to drink at least eight glasses of water a day." 4. "I'll have to catheterize my pouch every 2 hours."

Answer 1: RATIONALES: An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection (UTI). Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.

77. A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for: 1. cardiac arrhythmia. 2. paresthesia. 3. dehydration. 4. pruritus.

Answer 1: RATIONALES: As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In a client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.

When caring for a client with acute renal failure (ARF), the nurse expects to adjust the dosage or dosing schedule of certain drugs. Which of the following drugs would not require such adjustment? 1. acetaminophen (Tylenol) 2. gentamicin sulfate (Garamycin) 3. cyclosporine (Sandimmune) 4. ticarcillin disodium (Ticar)

Answer 1: RATIONALES: Because acetaminophen is metabolized in the liver, its dosage and dosing schedule need not be adjusted for a client with ARF. In contrast, the dosages and schedules for gentamicin and ticarcillin, which are metabolized and excreted by the kidney, should be adjusted. Because cyclosporine may cause nephrotoxicity, the nurse must monitor both the dosage and blood drug level in a client receiving this drug.

15. A 75-year-old client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin (Garamycin), which can be nephrotoxic. Which laboratory value should be closely monitored? 1. Blood urea nitrogen 2. Sodium level 3. Alkaline phosphatase 4. White blood cell (WBC) count

Answer 1: RATIONALES: Blood urea nitrogen and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.

95. The nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? 1. Encouraging intake of at least 2 L of fluid daily 2. Giving the client a glass of soda before bedtime 3. Taking the client to the bathroom twice per day 4. Consulting with a dietitian

Answer 1: RATIONALES: By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.

14. A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes: 1. confusion, headache, and seizures. 2. acute bone pain and confusion. 3. weakness, tingling, and cardiac arrhythmias. 4. hypotension, tachycardia, and tachypnea.

Answer 1: RATIONALES: Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiological functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication.

18 A client is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include: 1. generalized edema, especially of the face and periorbital area. 2. green-tinged urine. 3. moderate to severe hypotension. 4. polyuria.

Answer 1: RATIONALES: Generalized edema, especially of the face and periorbital area, is a classic sign of acute glomerulonephritis of sudden onset. Other classic signs and symptoms of this disorder include hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting. The client also may have moderate to severe hypertension (not hypotension), oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.

58. The nurse is planning to administer a sodium polystyrene sulfonate (Kayexalate) enema to a client with a potassium level of 6.2 mEq/L. Correct administration and the effects of this enema would include having the client: 1. retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. 2. retain the enema for 30 minutes to allow for glucose exchange; afterward, the client should have diarrhea. 3. retain the enema for 60 minutes to allow for sodium exchange; diarrhea isn't necessary to reduce the potassium level. 4. retain the enema for 60 minutes to allow for glucose exchange; diarrhea isn't necessary to reduce the potassium level.

Answer 1: RATIONALES: Kayexalate is a sodium-exchange resin. Thus, the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, Kayexalate must be in contact with the bowel for at least 30 minutes. Sorbitol in the Kayexalate enema causes diarrhea, which increases potassium loss and decreases the potential for Kayexalate retention.

29. A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? 1. Transurethral resection of the prostate (TURP) 2. Suprapubic prostatectomy 3. Retropubic prostatectomy 4. Transurethral laser incision of the prostate

Answer 1: RATIONALES: TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; they all require an incision.

56. A client with a genitourinary problem is being examined in the emergency department. When palpating the client's kidneys, the nurse should keep in mind which anatomic fact? 1. The left kidney usually is slightly higher than the right one. 2. The kidneys are situated just above the adrenal glands. 3. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾″ to 1-1/8″) wide. 4. The kidneys lie between the 10th and 12th thoracic vertebrae.

Answer 1: RATIONALES: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼″) wide, and 2.5 cm (1″) thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.

85. A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? 1. Kidney 2. Ureter 3. Bladder 4. Urethra

Answer 1: RATIONALES: The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.

75. Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes neck vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? 1. Place the client on bed rest. 2. Provide a high-protein, fluid-restricted diet. 3. Prepare to assist with insertion of a Tenckhoff catheter for hemodialysis. 4. Place the client on a sheepskin, and monitor for increasing edema.

Answer 1: RATIONALES: The nurse immediately must enforce bed rest for a client with glomerulonephritis to ensure a complete recovery and help prevent complications. Depending on disease severity, the client may require fluid, sodium, potassium, and protein restrictions. Because of the risk of altered urinary elimination related to oliguria, this client may require hemodialysis or plasmapheresis for several weeks until renal function improves; however, a Tenckhoff catheter is used in peritoneal dialysis, not hemodialysis. Although comfort measures such as placing the client on a sheepskin are important, they don't take precedence.

88. After undergoing renal arteriogram, in which the left groin was accessed, the client complains of left calf pain. Which intervention should the nurse perform first? 1. Assess peripheral pulses in the left leg. 2. Place cool compresses on the calf. 3. Exercise the leg and foot. 4. Assess for anaphylaxis.

Answer 1: RATIONALES: The nurse should begin by assessing peripheral pulses in the left leg to determine if blood flow was interrupted by the procedure. The client may also have thrombophlebitis. Cool compresses aren't used to relieve pain and inflammation in thrombophlebitis. The leg should remain straight after the procedure. Calf pain isn't a symptom of anaphylaxis.

9. The nurse is caring for a 25-year-old female client diagnosed with a chlamydia infection. The nurse teaches the client about disease transmission and advises the client to inform her sexual partners of the infection. The client refuses, stating, "This is my business and I'm not telling anyone. Beside, chlamydia doesn't cause any harm like the other STDs." How should the nurse proceed? 1. Educate the client about why it's important to inform sexual contacts so they can receive treatment. 2. Inform the health department that this client contracted a sexually transmitted disease. 3. Inform the client's sexual contacts of their possible exposure to chlamydia. 4. Do nothing because the client's sexual habits place her at risk for contracting other sexually transmitted diseases.

Answer 1: RATIONALES: The nurse should educate the client about the disease and how it impacts a person's health. Further education allows the client to make an informed decision about notifying sexual contacts. The nurse must maintain client confidentiality unless law mandates reporting the illness; contacting sexual contacts breeches client confidentiality. Option 4 is judgmental; everyone is entitled to health care regardless of their health habits.

86. A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner should be involved in the client's care to: 1. assess whether the client is a good candidate for surgery. 2. help the client cope with the anxiety associated with changes in body image. 3. assess suicidal risk postoperatively. 4. evaluate the client's need for mental health intervention.

Answer 2 RATIONALES: Many clients who undergo surgery for creation of an ileal conduit experience anxiety associated with changes in body image. The mental health practitioner can help with client cope these feelings of anxiety. Mental health practitioners don't evaluate whether the client is a surgical candidate. None of the evidence suggests that urinary diversion surgery, such as creation of an ileal conduit, places the client at risk for suicide. Although evaluating the need for mental health intervention is always important, this client displays no behavioral changes that suggest intervention is necessary at this time.

65. A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should: 1. start with the first voiding. 2. start after a known voiding. 3. always be with the first morning urine. 4. always be the evening's last void as the last sample.

Answer 2 RATIONALES: When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isn't important but it's commonly started in the morning.

8. A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about: 1. chronic, excessive acetaminophen use. 2. recent streptococcal infection. 3. childhood asthma. 4. family history of pernicious anemia.

Answer 2: RATIONALES: A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction.

93. Which conditions are functions of antidiuretic hormone (ADH)? 1. Sodium absorption and potassium excretion 2. Water reabsorption and urine concentration 3. Water reabsorption and urine dilution 4. Sodium reabsorption and potassium retention

Answer 2: RATIONALES: ADH stimulates the renal tubules to reabsorb water, thereby concentrating urine. Aldosterone is responsible for sodium reabsorption and potassium excretion by the kidneys.

67. A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for: 1. enuresis. 2. drug toxicity. 3. lethargy. 4. insomnia.

Answer 2: RATIONALES: Acute renal failure is characterized by oliguria and rapid accumulation of nitrogen waste in the blood. Kidneys excrete medications, so the nurse should monitor the client closely for drug toxicity. With decreased urinary output or no output, enuresis shouldn't occur. The client will most likely feel lethargic, but this isn't as serious a problem as drug toxicity. The client isn't likely to have insomnia, but, may instead want to sleep most of the time.

38. Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure? 1. Blood glucose level of 200 mg/dl 2. White blood cell (WBC) count of 20,000/mm3 3. Potassium level of 3.5 mEq/L 4. Hematocrit (HCT) of 35%

Answer 2: RATIONALES: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

57. A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: 1. hematuria. 2. weight loss. 3. increased urine output. 4. increased blood pressure.

Answer 2: RATIONALES: Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.

28. A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl. The most therapeutic pharmacologic intervention would be to administer: 1. ferrous sulfate (Feratab). 2. epoetin alfa (Epogen) 3. filgrastim (Neupogen) 4. enoxaparin (Lovenox)

Answer 2: RATIONALES: Chronic renal failure diminishes the production of erythropoietin by the kidneys and leads to a subnormal Hb level. (Normal Hb level is 13 to 18 g/dl in men and 12 to 16 g/dl in women.) An effective pharmacologic treatment for this is epoetin alfa, a recombinant erythropoietin. Because the client's anemia is caused by a deficiency of erythropoietin and not a deficiency of iron, administering ferrous sulfate would be ineffective. Neither filgrastim, a drug used to stimulate neutrophils, nor enoxaparin (low-molecular-weight heparin) will raise the client's Hb level.

43. A client with suspected renal dysfunction is scheduled for excretory urography. The nurse reviews the history for conditions that may warrant changes in client preparation. Normally, a client should be mildly hypovolemic (fluid depleted) before excretory urography. Which history finding would call for the client to be well hydrated instead? 1. Cystic fibrosis 2. Multiple myeloma 3. Gout 4. Myasthenia gravis

Answer 2: RATIONALES: Fluid depletion before excretory urography is contraindicated in clients with multiple myeloma, severe diabetes mellitus, and uric acid nephropathy — conditions that can seriously compromise renal function in fluid-depleted clients with reduced renal perfusion. If these clients must undergo excretory urography, they should be well hydrated before the test. Cystic fibrosis, gout, and myasthenia gravis don't necessitate changes in client preparation for excretory urography.

31. The physician prescribes norfloxacin (Noroxin), for a client with a urinary tract infection (UTI). The client asks the nurse how long to continue taking the drug. For an uncomplicated UTI, the usual duration of norfloxacin therapy is: 1. 3 to 5 days. 2. 7 to 10 days. 3. 12 to 14 days. 4. 10 to 21 days.

Answer 2: RATIONALES: For an uncomplicated UTI, norfloxacin therapy usually lasts 7 to 10 days. Taking the drug for less than 7 days wouldn't eradicate such an infection. Taking it for more than 10 days isn't necessary. Only a client with a complicated UTI must take norfloxacin for 10 to 21 days.

74. A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? 1. Chlamydia 2. Gonorrhea 3. Genital herpes 4. Human papillomavirus infection

Answer 2: RATIONALES: Gonorrhea must be reported to the public health department. Chlamydia, genital herpes, and human papillomavirus infection aren't reportable diseases.

76. A client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? 1. The skin wasn't lubricated before the pouch was applied. 2. The pouch faceplate doesn't fit the stoma. 3. A skin barrier was applied properly. 4. Stoma dilation wasn't performed.

Answer 2: RATIONALES: If the pouch faceplate doesn't fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn't be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn't performed with an ileal conduit, although it may be done with a colostomy if ordered.

90. A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? 1. "Take your temperature every 4 hours." 2. "Increase your fluid intake to 2 to 3 L per day." 3. "Apply an antibacterial dressing to the incision daily." 4. "Be aware that your urine will be cherry-red for 5 to 7 days."

Answer 2: RATIONALES: Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision. Hematuria may occur for a few hours after lithotripsy but should then disappear.

100. The physician enters a computer order for the nurse to irrigate a client's nephrostomy tube every four hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is: 1. appropriate because the irrigation just checks for patency. 2. inappropriate because irrigation requires strict sterile technique. 3. appropriate because the irrigation set will only be used during an 8-hour period. 4. inappropriate because the sterile drape must be cloth, not paper.

Answer 2: RATIONALES: Irritating a nephrostomy tube requires strict sterile technique; therefore, reusing the irrigation set (even if covered by a sterile drape) is inappropriate. Bacteria can proliferate inside the syringe and irrigation container. Although this procedure checks patency, it requires sterile technique to prevent the introduction of bacteria into the kidney. The material in which the sterile drape is made is irrelevant because a sterile drape doesn't deter bacterial growth in the irrigation equipment

46. A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by: 1. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. 2. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. 3. draining urine from the drainage bag into a sterile container. 4. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

Answer 2: RATIONALES: Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.

32. The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? 1. Specific gravity of 1.03 2. Urine pH of 3.0 3. Absence of protein 4. Absence of glucose

Answer 2: RATIONALES: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

97. The nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? 1. Fluid intake should be double the urine output. 2. Fluid intake should be approximately equal to the urine output. 3. Fluid intake should be half the urine output. 4. Fluid intake should be inversely proportional to the urine output.

Answer 2: RATIONALES: Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.

48. After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? 1. The urine in the drainage bag appears red to pink. 2. The client reports bladder spasms and the urge to void. 3. The normal saline irrigant is infusing at a rate of 50 drops/min. 4. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned.

Answer 2: RATIONALES: Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/min or according to facility protocol. The amount of returned fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency.

19. The nurse suspects that a client with a temperature of 103.6° F (39.8° C) and an elevated white blood cell count is in the initial stage of sepsis. What is the most common cause of sepsis in hospitalized clients? 1. Respiratory infection 2. Urinary tract infection (UTI) 3. Vasculitis 4. Osteomyelitis

Answer 2: RATIONALES: Sepsis most commonly results from a UTI caused by gram-negative bacteria. Other causes of sepsis include infections of the biliary, GI, and gynecologic tracts. Respiratory infection, vasculitis, and osteomyelitis rarely cause sepsis in hospitalized clients.

34. A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the client: 1. she will be in a private room with unrestricted activities. 2. a bowel-cleansing procedure will precede radioactive implantation. 3. she will be expected to use a bedpan for urination. 4. the preferred position in bed will be semi-Fowler's.

Answer 2: RATIONALES: The client will receive an enema before the procedure because bowel motility during cervical radiation implant therapy can disrupt or dislodge the implants. The client will be in a private room, and activities will be restricted in order to keep the implants in place. To keep the bladder empty, an indwelling catheter will be used. Positioning in bed shouldn't exceed a 20-degree elevation because sitting up can cause the implants to move from their intended locations. Semi-Fowler's position is 45 degrees.

44. An 85-year-old client is transferred from a local assisted living center to the emergency department with depression and behavioral changes. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed? 1. Notify the physician of her findings immediately. 2. Attend to the client's physiological needs. 3. Notify the client's family. 4. Notify the rape crisis team.

Answer 2: RATIONALES: The nurse should attend to the client's immediate physiological needs including physical safety. Next, the nurse can notify the physician and the rape crisis team. The family should be notified if the client consents, but not until the rape investigation is complete.

53. When a client with an indwelling urinary catheter insists on walking to the hospital lobby to visit with family members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? 1. The client sets the drainage bag on the floor while sitting down. 2. The client keeps the drainage bag below the bladder at all times. 3. The client clamps the catheter drainage tubing while visiting with the family. 4. The client loops the drainage tubing below its point of entry into the drainage bag.

Answer 2: RATIONALES: To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.

80. Which statement describing urinary incontinence in the elderly is true? 1. Urinary incontinence is a normal part of aging. 2. Urinary incontinence isn't a disease. 3. Urinary incontinence in the elderly can't be treated. 4. Urinary incontinence is a disease.

Answer 2: RATIONALES: Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured.

47. The nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to: 1. ask all potential sexual partners if they have a sexually transmitted disease. 2. wear a condom every time he has intercourse. 3. consider intercourse safe if his partner has no visible discharge, lesions, or rashes. 4. expect to limit the number of sexual partners to less than five over his lifetime.

Answer 2: RATIONALES: Wearing a condom during intercourse considerably reduces the risk of contracting STDs. The other options may help reduce the risk of contracting an STD but not to the extent wearing a condom will. A monogamous relationship also reduces the risk of contracting STDs.

26. The nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: 1. initiate a stream of urine. 2. breathe deeply. 3. turn to the side. 4. hold the labia or shaft of the penis.

Answer 2: RATIONALES: When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, and doing so may contaminate the sterile field.

16. A client with a urinary tract infection is prescribed co-trimoxazole (trimethoprim-sulfamethoxazole). The nurse should provide which medication instruction? 1. "Take the medication with food." 2. "Drink at least eight 8-oz glasses of fluid daily." 3. "Avoid taking antacids during co-trimoxazole therapy." 4. "Don't be afraid to go out in the sun."

Answer 2: RATIONALES: When receiving a sulfonamide such as co-trimoxazole, the client should drink at least eight 8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy.

68. During rectal examination, which finding would be further evidence of a urethral injury? 1. A low-riding prostate 2. The presence of a boggy mass 3. Absent sphincter tone 4. A positive Hemoccult

Answer 2: RATIONALES: When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury.

99. Which clinical finding would the nurse look for in a client with chronic renal failure? 1. Hypotension 2. Uremia 3. Metabolic alkalosis 4. Polycythemia

Answer 2; RATIONALES: Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure.

41. Which of the following is an appropriate nursing diagnosis for a client with renal calculi? 1. Ineffective renal tissue perfusion 2. Functional urinary incontinence 3. Risk for infection 4. Decreased cardiac output

Answer 3 RATIONALES: Infection can occur with renal calculi from urine stasis caused by obstruction. Options 1 and 4 aren't appropriate for this client, and retention of urine, rather than incontinence, usually occurs.

91. After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse inquires about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility? 1. Chickenpox 2. Measles 3. Mumps 4. Scarlet fever

Answer 3 RATIONALES: Mumps is the childhood infectious disease that most significantly affects male fertility. Chickenpox, measles, and scarlet fever don't affect male fertility.

1. The nurse is caring for a male client with gonorrhea who's receiving ceftriaxone and doxycycline. The client asks the nurse why he's receiving two antibiotics. How should the nurse respond? 1. "Because there are many resistant strains of gonorrhea, more than one antibiotic may be required for successful treatment." 2. "The combination of these two antibiotics reduces the risk of reinfection." 3. "Many people infected with gonorrhea are infected with chlamydia as well." 4. "This combination of medications will eradicate the infection faster than a single antibiotic."

Answer 3: Answer 3: RATIONALES: Treatment for gonorrhea includes the antibiotic ceftriaxone. Because many people with gonorrhea have a coexisting chlamydial infection, doxycycline or azithromycin is prescribed as well. There has been an increase in the number of resistant strains of gonorrhea, but that isn't the reason for this dual therapy. This combination of antibiotics doesn't reduce the risk of reinfection or provide a faster cure.

25. A client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: 1. keep the client's knee on the affected side bent for 6 hours. 2. apply pressure to the puncture site for 30 minutes. 3. check the client's pedal pulses frequently. 4. remove the dressing on the puncture site after vital signs stabilize.

Answer 3: RATIONALES: After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn't remove this dressing for several hours — and only if instructed to do so.

33. After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should the nurse do first? 1. Increase the I.V. flow rate. 2. Notify the physician immediately. 3. Assess the irrigation catheter for patency and drainage. 4. Administer morphine sulfate, 2 mg I.V., as prescribed.

Answer 3: RATIONALES: Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as morphine sulfate, as prescribed. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn't necessary unless the pain is severe or unrelieved by the prescribed medication.

11. A client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen? 1. Urine output increases to 2,000 ml/day. 2. Flank and abdominal discomfort decrease. 3. Bacteria are absent on urine culture. 4. The red blood cell (RBC) count is normal.

Answer 3: RATIONALES: Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isn't a reliable indicator of the drug's effectiveness. Co-trimoxazole doesn't affect urine output or the RBC count

21. For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? 1. Encouraging coughing and deep breathing 2. Promoting carbohydrate intake 3. Limiting fluid intake 4. Providing pain-relief measures

Answer 3: RATIONALES: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

83. A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction? 1. "Be sure to eat meat at every meal." 2. "Eat plenty of bananas." 3. "Increase your carbohydrate intake." 4. "Drink plenty of fluids, and use a salt substitute."

Answer 3: RATIONALES: Extra carbohydrates are needed to prevent protein catabolism. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided.

7. The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: 1. hypernatremia. 2. hypokalemia. 3. hyperkalemia. 4. hypercalcemia.

Answer 3: RATIONALES: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

60. Which statement best describes the therapeutic action of loop diuretics? 1. They block reabsorption of potassium on the collecting tubule. 2. They promote sodium secretion into the distal tubule. 3. They block sodium reabsorption in the ascending loop and dilate renal vessels. 4. They promote potassium secretion into the distal tubule and constrict renal vessels.

Answer 3: RATIONALES: Loop diuretics block sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels. Loop diuretics block potassium reabsorption, but this isn't a therapeutic effect. Thiazide diuretics promote sodium secretion into the distal tubule.

17. The nurse correctly identifies a urine sample with a pH of 4.3 as being which type of solution? 1. Neutral 2. Alkaline 3. Acidic 4. Basic

Answer 3: RATIONALES: Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.

101. Which steps should the nurse follow to insert a straight urinary catheter? 1. Create a sterile field, drape the client, clean the meatus, and insert the catheter only 6". 2. Put on gloves, prepare equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6". 3. Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. 4. Prepare the client and equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows.

Answer 3: RATIONALES: Option 3 describes all the vital steps for inserting a straight catheter. Option 1 is incorrect because the nurse must prepare the client and equipment before creating a sterile field. Option 2 is incorrect because the nurse put on gloves before creating a sterile field and performing the other tasks. Option 4 describes the procedure for inserting a retention catheter, rather than a straight catheter.

98. Which laboratory value supports a diagnosis of pyelonephritis? 1. Myoglobinuria 2. Ketonuria 3. Pyuria 4. Low white blood cell (WBC) count

Answer 3: RATIONALES: Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option 4. Ketonuria indicates a diabetic state.

82. A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: 1. nausea and vomiting. 2. dyspnea and cyanosis. 3. fatigue and weakness. 4. thrush and circumoral pallor.

Answer 3: RATIONALES: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.

66. A female client reports to the nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: 1. functional incontinence. 2. reflex incontinence. 3. stress incontinence. 4. total incontinence.

Answer 3: RATIONALES: Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

79. To treat a urinary tract infection (UTI), a client is prescribed sulfamethoxazole (Gantanol). The nurse should teach the client that sulfamethoxazole is most likely to cause which adverse effect? 1. Anxiety 2. Headache 3. Diarrhea 4. Dizziness

Answer 3: RATIONALES: Sulfamethoxazole is most likely to cause diarrhea. Nausea and vomiting are other common adverse effects. This drug rarely causes anxiety, headache, or dizziness.

59. The registered nurse and nursing assistant are caring for a group of clients. Which client's care can safely be delegated to the nursing assistant? 1. A 35-year-old client who underwent surgery 12 hours ago and has a suprapubic catheter in place that is draining burgundy colored urine 2. A 63-year-old client with uncontrolled diabetes mellitus who underwent radical suprapubic prostatectomy 1 day ago and has an indwelling urinary catheter draining yellow urine with clots 3. A 45-year-old client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids. 4. A 19-year-old client who requires neurological assessment every four hours after sustaining a spinal cord injury in a motor vehicle accident that left him with paraplegia

Answer 3: RATIONALES: The care of the client in option 3 can safely be delegated to the nursing assistant. The client in option 1 had surgery 12 hours ago; therefore, the registered nurse should care for the client because the client requires close assessment. The client in option 2 also requires careful assessment by the registered nurse because the client's diabetes mellitus is uncontrolled. In addition, the registered nurse should care for the client in option 4 because the client requires neurological assessment, which isn't within the scope of practice for the nursing assistant.

64. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: 1. limit oral fluid intake for 1 to 2 weeks. 2. report the presence of fine, sandlike particles through the nephrostomy tube. 3. notify the physician about cloudy or foul-smelling urine. 4. report bright pink urine within 24 hours after the procedure.

Answer 3: RATIONALES: The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy.

72. After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an I.V. infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that is draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last two consecutive hours. How can the nurse best explain this drop in urine output? 1. It's a normal finding caused by blood loss during surgery. 2. It's a normal finding associated with the client's nothing-by-mouth status. 3. It's an abnormal finding that requires further assessment. 4. It's an abnormal finding that will correct itself when the client ambulates.

Answer 3: RATIONALES: The drop in urine output to less than 30 ml/hour is abnormal and requires further assessment. The reduction in urine output may be caused by an obstruction in the urinary catheter tubing or deficient fluid volume from blood loss. The client's nothing-by-mouth status isn't the cause of the low urine output because the client is receiving I.V. fluid to compensate for the lack of oral intake. Ambulation promotes urination; however, the client should produce at least 30 ml of urine/hour

61. A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? 1. Increased pH with decreased hydrogen ions 2. Increased serum levels of potassium, magnesium, and calcium 3. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl 4. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%

Answer 3: RATIONALES: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option 3 are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.

37. A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, the nurse finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram. 1. Increased alertness 2. Hypoventilation 3. Pruritus 4. Unusually smooth skin

Answer 3: RATIONALES: The nurse should be alert for urticaria and pruritus, which may indicate a mild anaphylactic reaction to the arteriogram dye. Decreased (not increased) alertness may occur as well as dyspnea (not hypoventilation). Unusually smooth skin isn't a sign of anaphylaxis.

92. A 75-year-old client undergoes total hip replacement. After surgery, the client questions why she must go to a rehabilitation center because she has family who can care for her. Which response by the nurse is best? 1. You'll need help with your bath and meals for quite some time." 2. "The rehabilitation staff can provide you with better care." 3. "The rehabilitation staff can evaluate your progress and make sure that you exercise without risking injury." 4. "The doctor wants you to go to the rehabilitation center until you're fully recovered and able to care for yourself."

Answer 3: RATIONALES: The nurse should respond by emphasizing that the rehabilitation center can evaluate progress and make sure that exercises are performed without risking injury. This response points out that the goal of rehabilitation is safely achieving mobility, not providing total care. Option 1 doesn't provide adequate information about the role of rehabilitation or the client's future needs. The rehabilitation center will help the client learn to bathe herself. Option 2 is judgmental about care the family might provide and doesn't adequately explain the role of a rehabilitation center. Option 4 doesn't explain the importance of a rehabilitation center.

62. A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is most appropriate for this client? 1. Impaired urinary elimination 2. Toileting self-care deficit 3. Risk for infection 4. Activity intolerance

Answer 3: RATIONALES: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. Therefore, the client is at risk for infection. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. The other options may be pertinent but are secondary to the risk for infection.

94. The nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point would the nurse want to include? 1. Limit fluid intake to reduce the need to urinate. 2. Take medication prescribed for a UTI until the symptoms subside. 3. Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. 4. Wear only nylon underwear to reduce the chance of irritation.

Answer 3: RATIONALES: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. The client should notify his physician so that a microscopic urinalysis can be done and appropriate treatment can be initiated. The client should be instructed to drink 2 to 3 L of fluid per day to dilute the urine and reduce irritation of the bladder mucosa. The full amount of antibiotics prescribed for UTIs must be taken despite the fact that the symptoms may have subsided. This will help to prevent recurrences of UTI. Women are told to avoid scented toilet tissue and bubble baths and to wear cotton underwear, not nylon, to reduce the chance of irritation.

13. The nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 95 ml. Urine output that's less than 100 ml in 24 hours is known as: 1. oliguria. 2. polyuria. 3. anuria. 4. hematuria.

Answer 3: RATIONALES: Urine output less than 100 ml in 24 hours is called anuria. Urine output of less than 400 ml but more than 100 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine.

35. A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? 1. Blood pressure 2. Respirations 3. Temperature 4. Pulse

Answer 4 RATIONALES: An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.

36. The nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention? 1. Rashes on the palms of the hands and soles of the feet 2. Cauliflower-like warts on the penis 3. Painful red papules on the shaft of the penis 4. Foul-smelling discharge from the penis

Answer 4 RATIONALES: Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.

42. A client with a history of chronic cystitis comes to the 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? 1. Cranberry juice 2. Coffee 3. Prune juice 4. Milk

Answer 4: RATIONALES: 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.

81. When performing a scrotal examination, the nurse finds a nodule. What should the nurse do next? 1. Notify the physician. 2. Change the client's position and repeat the examination. 3. Perform a rectal examination. 4. Transilluminate the scrotum.

Answer 4: RATIONALES: A nurse who discovers a nodule, swelling, or other abnormal finding during a scrotal examination should transilluminate the scrotum by darkening the room and shining a flashlight through the scrotum behind the mass. A scrotum filled with serous fluid transilluminates as a red glow; a more solid lesion, such as a hematoma or mass, doesn't transilluminate and may appear as a dark shadow. Although the nurse should notify the physician of the abnormal finding, performing transillumination first provides additional information. The nurse can't uncover more information about a scrotal mass by changing the client's position and repeating the examination or by performing a rectal examination.

12. A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hr. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? 1. Blood urea nitrogen (BUN) level of 22 mg/dl 2. Serum creatinine level of 1.2 mg/dl 3. Temperature of 100.2° F (37.8° C) 4. Urine output of 250 ml/24 hours

Answer 4: RATIONALES: ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is demonstrated by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

30. During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by: 1. slowing the glomerular filtration rate. 2. increasing sodium resorption. 3. decreasing potassium excretion. 4. stimulating or hindering micturition.

Answer 4: RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion.

39. A client requires hemodialysis. Which type of drug should be withheld before this procedure? 1. Phosphate binders 2. Insulin 3. Antibiotics 4. Cardiac glycosides

Answer 4: RATIONALES: Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.

73. The nurse is teaching a client with genital herpes. Education for this client should include an explanation of: 1. the need for the use of petroleum products. 2. why the disease is transmittable only when visible lesions are present. 3. the option of disregarding safer-sex practices now that he's already infected. 4. the importance of informing his partners of the disease.

Answer 4: RATIONALES: Clients with genital herpes should inform their partners of the disease. Petroleum products should be avoided because they can cause the virus to spread. The notion that genital herpes is only transmittable when visible lesions are present is false. Anyone not in a long-term, monogamous relationship, regardless of current health status, should follow safer-sex practices

71. The nurse is caring for a client with acute renal failure. The nurse should expect that hypertonic glucose, insulin infusions, and sodium bicarbonate will be used to treat what complication of acute renal failure? 1. Hypokalemia 2. Hyperphosphatemia 3. Hypophosphatemia 4. Hyperkalemia

Answer 4: RATIONALES: Hyperkalemia is a common complication of acute renal failure. The administration of glucose and regular insulin infusions, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing potassium levels. This treatment isn't used to treat hyperphosphatemia or hypophosphatemia.

54. The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate? 1. Tell the client to try to urinate around the catheter to remove blood clots. 2. Restrict fluids to prevent the client's bladder from becoming distended. 3. Prepare to remove the catheter. 4. Use aseptic technique when irrigating the catheter.

Answer 4: RATIONALES: If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. Encourage the client to drink fluids to dilute the urine and maintain urine output. The catheter remains in place for 2 to 4 days after surgery and is only removed with a physician's order.

4. A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? 1. Poor perfusion to the kidneys 2. Damage to cells in the adrenal cortex 3. Obstruction of the urinary collecting system 4. Nephrotoxic injury secondary to use of contrast media

Answer 4: RATIONALES: Intrinsic renal failure results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure.

55. A 25-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She's placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which is the most likely medication prescribed for the pain? 1. nitrofurantoin (Macrodantin) 2. ibuprofen (Motrin) 3. acetaminophen with codeine 4. phenazopyridine (Pyridium)

Answer 4: RATIONALES: Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. Although ibuprofen and acetaminophen with codeine are analgesics, they don't exert a direct effect on the urinary mucosa.

27. A client with heart failure admitted to an acute care facility and is found to have a cystocele. When planning care for this client, the nurse is most likely to formulate which nursing diagnosis? 1. Total urinary incontinence 2. Functional urinary incontinence 3. Reflex urinary incontinence 4. Stress urinary incontinence

Answer 4: RATIONALES: Stress urinary incontinence is a urinary problem associated with cystocele — herniation of the bladder into the birth canal. Other problems associated with this disorder include urinary frequency, urinary urgency, urinary tract infection (UTI), and difficulty emptying the bladder. Total incontinence, functional incontinence, and reflex incontinence usually result from neurovascular dysfunction, not cystocele.

6. A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? 1. Force oral fluids. 2. Administer furosemide (Lasix) 20 mg I.V. 3. Start hemodialysis after a temporary access is obtained. 4. Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose.

Answer 4: RATIONALES: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.

45. The client is scheduled for urinary diversion surgery to treat bladder cancer. Before surgery, the health care team consisting of a nurse, dietician, social worker, enterostomal therapist, surgeon, client educator, and mental health worker meet with the client. After the meeting, the client states, "My life won't ever be the same. What am I going to do?" Which health team member should the nurse consult to help with the client's concerns? 1. Social worker 2. Surgeon 3. Dietician 4. Client educator

Answer 4: RATIONALES: The nurse should consult the client educator to help the client with his fears and concerns. Providing the client with information can greatly allay the client's fears. The social worker can provide the client with services he may need after discharge. The dietician can help with dietary concerns but can't provide help with direct concerns about the surgery.

78. The nurse is providing inservice education for the staff about evidence collection after sexual assault. The educational session is successful when the staff focuses their initial care on which step? 1. Collecting semen 2. Performing the pelvic examination 3. Obtaining consent for examination 4. Supporting the client's emotional status

Answer 4: RATIONALES: The teaching session is successful when the nurses focus on supporting the client's emotional status first. Next, the nurses should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

16) Which is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery? 1. Covering the exposed intestines with sterile moist gauze 2. Wrapping the newborn warmly in two or three blankets 3. Providing a sterile water feeding to maintain hydration during transport 4. Allowing the parents of the newborn to see their child prior to transport

Answer: 1 Explanation: 1. It is important to keep the intestine from drying during transport. 2. Placement in a transport isolette would be preferred to wrapping due to the nature of the birth defect. 3. The newborn should be NPO. 4. While it is important for the parents to see their child before transport, this is not the priority nursing intervention.

1) Which clinical manifestations should the nurse anticipate when assessing a child who has been admitted to the hospital unit with a diagnosis of minimal change nephrotic syndrome (MCNS)? 1. Massive proteinuria, hypoalbuminemia, and edema 2. Hematuria, bacteriuria, and weight gain 3. Urine specific gravity decreased and urinary output increased 4. Gross hematuria, albuminuria, and fever

Answer: 1 Explanation: 1. Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. 2. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen. 3. In MCNS, the urine output decreases and the specific gravity of urine increases. 4. Gross hematuria and hypertension are associated with glomerulonephritis.

6) A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data? 1. Placing the newborn on a radiant warmer 2. Placing the newborn in an open crib 3. Preparing the newborn for phototherapy 4. Preparing the newborn for a bottlefeeding

Answer: 1 Explanation: 1. Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The newborn loses heat through the viscera; a warmer is indicated to prevent hypothermia. 2. The crib would not provide adequate maintenance of temperature control. 3. Phototherapy is used to treat hyperbilirubinemia, not an omphalocele defect. 4. The newborn will require surgical correction of the defect prior to initiating bottle or breast feeding.

10) A child returns from exploratory surgery following a gunshot wound to the abdomen. Which nursing intervention should be excluded for the plan of care? 1. Immediate initiation of oral feedings 2. Assessment of the surgical site 3. Administration of opioid narcotics for pain management 4. Visitation at the bedside

Answer: 1 Explanation: 1. The child will be NPO after an exploratory abdominal surgery. The nurse should exclude this from the child's plan of care. 2. The surgical site must be visualized frequently for bleeding. 3. Pain management is essential and opioid analgesics are often necessary after exploratory surgery. 4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.

22. A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: 1. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. 2. a decreased serum phosphate level secondary to kidney failure. 3. an increased serum calcium level secondary to kidney failure. 4. metabolic alkalosis secondary to retention of hydrogen ions.

Answer: 1 RATIONALES: A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

24. A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? 1. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. 2. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. 3. The potential for transmission to her sexual partner will be eliminated if condoms are used every time she and her partner have sexual intercourse. 4. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.

Answer: 1 RATIONALES: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

17) Which assessment questions should the nurse include in the psychosocial assessment to determine the effects of chronic renal failure treatments on the growth and development of a school-age child? Select all that apply. 1. "How does it make you feel to have to follow a special diet?" 2. "Do you take your medications every day?" 3. "How does it make you feel to undergo dialysis treatments?" 4. "Do you attend school each day?" 5. "How does it make you feel when your parents come home late from work?"

Answer: 1, 3 Explanation: 1. School-age children are often embarrassed about being seen as different from peers. It is appropriate for the nurse to ask the child how it feels to have to follow a special diet. 2. While it is important to assess medication use, this question is not appropriate for the psychosocial portion of the assessment. 3. School-age children are often embarrassed about being seen as different from peers. It is appropriate for the nurse to ask the child how it feels to have to undergo dialysis treatments. 4. While it is important to determine if the child attends school every day, this question is not appropriate for the psychosocial portion of the assessment. 5. This question will not help the nurse to determine the effects of the treatments for chronic renal failure on the child's growth and development.

11) Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent? 1. Bloody urine 2. One void since returning from surgery 3. Bladder spasms responding to pharmacologic intervention 4. Double diapering from the previous shift

Answer: 2 Explanation: 1. Bloody urine is expected in the immediate postoperative period. 2. A 10-month-old child will void more often than 1 time in 4 hours. This could indicate the stent is occluded. The surgeon should be notified. 3. This is a normal finding. 4. This is a desired finding and does not need to be reported to the surgeon.

3) An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data? 1. Necrotizing enterocolitis (NEC) 2. Ulcerative colitis (UC) 3. Crohn disease 4. Appendicitis

Answer: 2 Explanation: 1. NEC is usually seen in premature infants and generally not in an adolescent client. 2. Diarrhea and bloody stools are typical symptoms of UC. 3. The teen with Crohn disease might have abdominal pain and diarrhea, but stools usually do not have blood in them. 4. Appendicitis is not associated with bloody stools and usually not with diarrhea.

13) Which assessment finding, after the dialysate is drained during peritoneal dialysis for a child experiencing acute renal failure, would warrant further action by the nurse? 1. The dialysate is clear on return. 2. The volume of drained dialysate is less than the volume infused. 3. The child is restless, wanting to get up and play. 4. The child's vital signs are basically the same as were noted on infusion.

Answer: 2 Explanation: 1. This is a normal finding and does not require reporting. 2. This indicates fluids are being retained and is not desirable. The healthcare provider should be notified. 3. This could indicate the child is feeling better. It is a desired effect and does not require reporting to the healthcare provider. 4. This is an expected finding. No dramatic differences in vital signs should be noted.

2) Which is the appropriate nursing intervention when providing care to a child, diagnosed with nephrotic syndrome, who is edematous and on bed rest? 1. Monitor blood pressure every 30 minutes. 2. Reposition every 2 hours. 3. Limit visitors. 4. Encourage fluids.

Answer: 2 Explanation: 1. Vital signs are taken every 4 hours. 2. A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every 2 hours. 3. The child needs social interaction, so visitors should not be limited. 4. Fluids need to be monitored; they should not be encouraged.

13) A nasogastric tube to suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate? 1. Weight loss 2. Metabolic alkalosis 3. Dehydration 4. Hyperbilirubinemia

Answer: 2 Explanation: 1. Weight loss and inadequate nutrition are not the priority for this client. 2. When large quantities of gastric juice is removed, acid is lost and metabolic alkalosis follows. 3. The volume would not be sufficient to cause dehydration. 4. Hyperbilirubinemia is unrelated to gastric suction.

49. Which laboratory test is the most accurate indicator of a client's renal function? 1. Blood urea nitrogen 2. Creatinine clearance 3. Serum creatinine 4. Urinalysis

Answer: 2 RATIONALES: Creatinine clearance is the most accurate indicator of a client's renal function because it closely correlates with the kidney's glomerular filtration rate and tubular excretion ability. Results from the other options may be influenced by various conditions and aren't specific to renal disease.

3. The nurse is caring for a client with acute pyelonephritis. Which nursing intervention is most important? 1. Administering a sitz bath twice per day 2. Increasing fluid intake to 3 L/day 3. Using an indwelling urinary catheter to measure urine output accurately 4. Encouraging the client to drink cranberry juice to acidify the urine

Answer: 2 Answer 2: RATIONALES: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. This helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important interaction.

2) Which assessment data would cause the nurse to suspect that a 3-year-old child has Hirschsprung disease? 1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period 3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea

Answer: 3 Explanation: 1. Clay-colored stools and dark urine are not associated with Hirschsprung disease. 2. The infant with Hirschsprung disease often has delayed meconium stools. 3. These are symptoms of Hirschsprung disease in an older infant or child. 4. Diarrhea is not typical; obstruction is more likely.

8) Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client? 1. "We will change the colostomy bag with each wet diaper." 2. "We will expect a moderate amount of bleeding after cleansing the area around the stoma." 3. "We will watch for skin irritation around the stoma." 4. "We will use adhesive enhancers when we change the bag."

Answer: 3 Explanation: 1. Physical or chemical skin irritation can occur if the appliance is changed too frequently, or with each wet diaper. 2. Bleeding is usually attributable to excessive cleaning. 3. Skin irritation around the stoma should be assessed; it could indicate leakage. 4. Adhesive enhancers should be avoided on the skin of infants. Their skin layers are thin, and removal of the appliance can strip off the skin.

15) Which parental action, observed during a home care visit for an infant diagnosed with gastroesophageal reflux, requires intervention by the nurse? 1. The infant's formula has rice cereal added. 2. The mother holds the infant in a high Fowler position while feeding. 3. After feeding, the infant is placed in a car seat. 4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.

Answer: 3 Explanation: 1. Rice cereal thickens the formula and helps prevent regurgitation. This is appropriate. 2. This position will help prevent regurgitation and is appropriate. 3. Infant seats are not recommended, as they put pressure on the abdomen and may contribute to regurgitation. 4. Since dosing is small, it is appropriate to use a syringe for accurate measurement.

17) A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question? 1. Clear liquids today. NPO tomorrow 2. Type and cross-match for 1 unit of packed red blood cells. 3. Rectal temperatures every 4 hours 4. Start an intravenous line with D5NS at 20 mL per hour.

Answer: 3 Explanation: 1. This is appropriate in anticipation of surgery. 2. Although not always required during surgery, this would not be inappropriate planning for the surgical procedure. 3. Rectal temperatures are avoided due to the fragile state of the rectum. 4. An IV is appropriate for surgical access.

23. During rounds, a client admitted with gross hematuria asks the nurse about the physician's diagnosis. To facilitate effective communication, what should the nurse do? 1. Ask why the client is concerned about the diagnosis. 2. Change the subject to something more pleasant. 3. Provide privacy for the conversation. 4. Give the client some good advice.

Answer: 3 RATIONALES: Providing privacy for the conversation is a form of active listening, which focuses solely on the client's needs. Asking why the client is concerned, changing the subject, or giving advice tends to block therapeutic communication.

2. Trimethoprim and sulfamethoxazole (Bactrim) BID for 7 days is ordered for a patient who has a recurrent relapse of an Escherichia coli UTI. The nurse instructs the patient to a. take the antibiotic for the full 7 days, even if symptoms improve in a few days. b. return to the clinic in 3 days so that a urine culture can be done to evaluate the effectiveness of the drug. c. increase the effectiveness of the drug by taking it with cranberry juice to acidify the urine. d. take two of the pills a day for 5 days, and reserve the rest of the pills to take if the symptoms reappear.

Answer: A Rationale: Although an initial infection may be treated with a shorter course of antibiotics, the patient with a recurrent infection should take the antibiotic for 7 days. Success of treatment is evaluated by resolution of symptoms rather than by a repeat culture. Acidifying the urine when a patient is taking sulfa antibiotics may lead to stone formation. The patient is instructed to take all the antibiotics. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Implementation NCLEX: Physiological Integrity

26. Following rectal surgery, a patient voids about 50 ml of urine every 30 to 60 minutes. Which nursing action is most appropriate? a. Use an ultrasound scanner to check for residual urine after voiding. b. Have the patient take small amounts of fluid frequently throughout the day. c. Reassure the patient that this is normal after rectal surgery due to anesthesia. d. Monitor the patient's intake and output over the next few hours.

Answer: A Rationale: An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours. Cognitive Level: Application Text Reference: p. 1182 Nursing Process: Implementation NCLEX: Physiological Integrity

16. A patient with a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock-wave lithotripsy. Which information is most important for the nurse to collect after lithotripsy? a. Urine output b. Pain level c. Appearance of the site d. Patient temperature

Answer: A Rationale: Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to monitor the urine output. The patient may have pain as the stones pass and bruising at the site, but these are not unexpected. Extracorporeal shock wave lithotripsy (ESWL) is not associated with a risk for infection. Cognitive Level: Application Text Reference: p. 1172 Nursing Process: Assessment NCLEX: Physiological Integrity

27. A patient in the hospital has a history of urinary incontinence. Which nursing action will be included in the plan of care? a. Place a bedside commode near the patient's bed. b. Use an ultrasound scanner to check urine residual after the patient voids. c. Demonstrate the use of the Credé maneuver to the patient. d. Teach the use of Kegel exercises to strengthen the pelvic floor.

Answer: A Rationale: Environmental changes can make it easier for the patient to avoid incontinence for patients with urinary incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. Cognitive Level: Application Text Reference: p. 1181 Nursing Process: Planning NCLEX: Physiological Integrity

25. After her bath, a 62-year-old patient asks the nurse for a perineal pad, saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient? a. Teach the patient how to perform Kegel exercises. b. Demonstrate how to perform Credé's maneuver. c. Place commode at the patient's bedside. d. Assist the patient to the bathroom q3hr.

Answer: A Rationale: Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. Cognitive Level: Application Text Reference: pp. 1181-1184 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

23. Following an open-loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented? a. Assist the patient to take a 15-minute sitz bath. b. Encourage the patient to drink several glasses of water. c. Teach the patient how to do isometric perineal exercises. d. Insert a straight catheter and drain the bladder.

Answer: A Rationale: Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids, this would not be appropriate when the patient is experiencing retention. Kegel exercises are helpful in the prevention of incontinence. Catheter insertion increases the risk for infection. Cognitive Level: Application Text Reference: p. 1179 Nursing Process: Implementation NCLEX: Physiological Integrity

37. A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse discuss with the health care provider? a. Give ketorolac (Toradol) 10 mg PO PRN for pain. b. Infuse 5% dextrose in normal saline at 75 ml/hr. c. Obtain BUN, creatinine, and electrolytes in 2 hours. d. Order regular diet after patient is awake and alert.

Answer: A Rationale: The NSAIDs should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Implementation NCLEX: Physiological Integrity

30. A patient undergoes a nephrectomy for massive trauma to the kidney resulting from a fall from a scaffold. Which assessment data obtained postoperatively are most important to communicate to the surgeon? a. Blood pressure is 102/48. b. Urine output is 20 ml/hr for 2 hours. c. Crackles are heard at both lung bases. d. Incisional pain level is 8/10.

Answer: B Rationale: Because the urine output should be at least 0.5 ml/kg/hr, a 40-ml output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Assessment NCLEX: Physiological Integrity

7. After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient says, a. "I will have to stop having coffee and orange juice for breakfast." b. "I should start taking a high-potency multiple vitamin every morning." c. "I should call the doctor about increased bladder pain or odorous urine." d. "I will buy some calcium glycerophosphate (Prelief) at the pharmacy."

Answer: B Rationale: High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching. Cognitive Level: Application Text Reference: p. 1164 Nursing Process: Evaluation NCLEX: Physiological Integrity

5. A 34-year-old patient with diabetes mellitus is hospitalized with fever, anorexia, and confusion. The health care provider suspects acute pyelonephritis when the urinalysis reveals bacteriuria. An appropriate collaborative problem identified by the nurse for the patient is potential complication a. hydronephrosis. b. urosepsis. c. acute renal failure. d. chronic pyelonephritis.

Answer: B Rationale: Infection can easily spread from the kidney to the circulation, causing urosepsis. A patient with a urinary tract obstruction will be at risk for hydronephrosis. Acute renal failure is not a common complication of acute pyelonephritis unless urosepsis and septic shock develop. Chronic pyelonephritis may occur after recurrent upper UTIs. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Diagnosis NCLEX: Physiological Integrity

17. The composition of a patient's renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid a. spinach, chocolate, and tomatoes. b. organ meats and fish with fine bones. c. milk and dairy products. d. legumes and dried fruits.

Answer: B Rationale: Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones. Cognitive Level: Application Text Reference: pp. 1170-1171 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

32. A patient has a cystectomy and a Kock continent diversion created for treatment of bladder cancer. During postoperative teaching of the patient, it is important that the nurse include instructions regarding a. application of ostomy appliances. b. catheterization technique and schedule. c. use of barrier products for skin protection. d. analgesic use before emptying the pouch.

Answer: B Rationale: The Kock pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful. Cognitive Level: Application Text Reference: p. 1190 Nursing Process: Implementation NCLEX: Physiological Integrity

29. The nurse observes a nursing assistant (NA) doing all of the following when caring for a patient with a retention catheter. Which action requires that the nurse intervene? a. The NA uses an alcohol-based hand cleaner before performing catheter care. b. The NA disconnects the catheter from the drainage tube to obtain a specimen. c. The NA uses soap and water when cleaning around the urinary meatus. d. The NA tapes the catheter to the skin on the patient's upper inner thigh.

Answer: B Rationale: The catheter should not be disconnected from the drainage tube because this increases the risk for UTI. The other actions are appropriate and do not require any intervention. Cognitive Level: Application Text Reference: p. 1186 Nursing Process: Assessment NCLEX: Physiological Integrity

15. The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine and to a. report the pain level when the stone passed. b. collect the stone and bring it to the clinic. c. record the time that the stone passed. d. save a urine specimen to check for blood.

Answer: B Rationale: The patient should save the stone for analysis of the stone composition, which will help in determining treatment. Reporting the pain level and recording the time the stone passed are not essential. Hematuria is common with urinary calculi, so it is not necessary to test the urine for blood. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Implementation NCLEX: Physiological Integrity

33. Following a cystectomy, a patient has an ileal conduit created. The nurse identifies the nursing diagnosis of risk for infection related to altered urinary structures. An appropriate nursing intervention for this problem is to a. clamp the drainage bag while the patient sleeps. b. empty the drainage appliance every 2 to 3 hours or when it is one-third full. c. use liquid antiseptic in the appliance to decrease bacterial colonization. d. drain the conduit every 4 hours using a sterile catheter.

Answer: B Rationale: The patient with an ileal conduit will have an appliance to hold urine, which should be emptied to avoid reflux of urine back into the conduit. The drainage bag should not be clamped. The use of a liquid antiseptic will not decrease risk for infection. Unlike a continent pouch, the ileal conduit will drain continuously and is not drained with a catheter. Cognitive Level: Application Text Reference: p. 1193 Nursing Process: Implementation NCLEX: Physiological Integrity

34. Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in body function. c. ineffective health maintenance related to refusal to participate in care. d. self-care deficit, toileting, related to denial of altered body function.

Answer: B Rationale: The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. There are no data suggesting that the impact on lifestyle is a concern for the patient. The patient may be at risk for ineffective health maintenance if the lack of participation in care continues, but the patient's behavior is normal 2 days after surgery. The patient does not appear to be in denial. Cognitive Level: Application Text Reference: p. 1191 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

18. To prevent the recurrence of renal calculi, the nurse teaches the patient to a. avoid all sources of dietary calcium. b. drink diuretic fluids such as coffee. c. drink 2000 to 3000 ml of fluid a day. d. use a filter to strain all urine.

Answer: C Rationale: A fluid intake of 2000 to 3000 ml daily is recommended help flush out minerals before stones can form. Patients are not advised to avoid all calcium-containing foods and a high calcium intake may decrease the incidence of some types of stones. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones. Cognitive Level: Application Text Reference: p. 1172 Nursing Process: Implementation NCLEX: Physiological Integrity

10. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with a. antibiotics. b. antihypertensives. c. anticoagulants. d. corticosteroids.

Answer: C Rationale: Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Physiological Integrity

38. Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider? a. Dysuria b. Temperature 100.1° F c. Left-sided flank pain d. Hematuria

Answer: C Rationale: Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Assessment NCLEX: Physiological Integrity

19. In planning teaching for a patient with benign nephrosclerosis, the nurse should include instructions regarding a. measuring daily intake and output amounts. b. obtaining and documenting daily weights. c. monitoring and recording blood pressure. d. preventing bleeding caused by anticoagulants.

Answer: C Rationale: Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

24. A 78-year-old patient is admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. In developing a plan of care for the patient, an appropriate nursing intervention for the patient's incontinence is to a. insert an indwelling catheter. b. apply absorbent incontinent pads. c. assist the patient to the bathroom q2hr. d. restrict fluids after the evening meal.

Answer: C Rationale: In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for UTI. Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration. Cognitive Level: Application Text Reference: pp. 1183-1185 Nursing Process: Planning NCLEX: Physiological Integrity

13. A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first? a. Draw blood for blood urea nitrogen (BUN) and creatinine. b. Administer lorazepam (Ativan) 0.5 mg. c. Insert 16 French retention catheter. d. Schedule for IVP.

Answer: C Rationale: The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently. Cognitive Level: Application Text Reference: p. 1185 Nursing Process: Implementation NCLEX: Physiological Integrity

31. A patient undergoing a left ureterolithotomy returns to the surgical unit with a left ureteral catheter and a urethral catheter in place. When caring for the patient, the nurse will plan to a. aspirate the ureteral catheter if output decreases. b. clamp the ureteral catheter unless output from the urethral catheter stops. c. keep the patient on bed rest until the ureteral catheter is discontinued. d. teach the patient about home care for both catheters.

Answer: C Rationale: To avoid displacing the ureteral catheter, the patient is usually on bed rest until the catheter is removed. Aspiration of the ureteral catheter might damage tissue in the renal pelvis. The catheter is not clamped. The patient is not usually discharged with a ureteral catheter in place. Cognitive Level: Application Text Reference: p. 1187 Nursing Process: Planning NCLEX: Physiological Integrity

20. A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Differences between hemodialysis and peritoneal dialysis b. Complications of renal transplantation c. Methods for treating chronic and severe pain d. Importance of genetic counseling

Answer: D Rationale: Because a 32-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain. Cognitive Level: Application Text Reference: p. 1176 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

6. A 72-year-old patient with benign prostatic hyperplasia and a history of frequent UTIs is admitted to the hospital with chills, fever, and nausea and vomiting. To determine whether the patient has an upper UTI, the nurse will assess for a. suprapubic pain. b. foul-smelling urine. c. bladder distension. d. costovertebral angle (CVA) tenderness.

Answer: D Rationale: CVA tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse takes care of a newborn diagnosed with Eagle-Barrett syndrome. Which comment by the parent indicates teaching was effective? a. "As a teen, my child might develop end-stage renal disease." b. "My infant has about 3 months to live due to severe renal problems." c. "The skin of his bottom looks like a prune due to poor peristalsis." d. "He has this syndrome from a recessive gene; my next baby will have it too

Answer: a. "As a teen, my child might develop end-stage renal disease." Feedback: Children with Eagle-Barrett syndrome (prune belly) will develop end-stage renal disease in childhood or adolescence because of inadequate renal function. The skin covering the abdominal wall is thin and resembles a wrinkled prune. Death occurs in the neonatal period due to pulmonary hypoplasia and severe renal dysfunction. Prune belly syndrome is thought to be related to a fetal urinary tract obstruction or a specific injury, not genetics

The mother of a 6-year-old calls the clinic because her child is wetting the bed. Which assessment question by the nurse is most important? a. "Is there a family history of renal or urinary problems?" b. "What happens when the child wets the bed?" c. "At what age was the child potty-trained?" d. "How is the child doing in school?"

Answer: a. "Is there a family history of renal or urinary problems?" Feedback: Enuresis more often occurs in children who have a positive family history, so the primary assessment question is to determine whether there is a family history. The other questions are important to ask when assessing a child with enuresis, but are not the priority.

Assessment of a 2-year-old by a nurse in the emergency department reveals the following: edema, hematuria, hypertension, and oliguria. What would the nurse assess as the most likely cause of these symptoms? a. Acute renal failure b. Urinary tract infection c. Vesicoureteral reflux d. Bladder exstrophy

Answer: a. Acute renal failure Feedback: There are several things that can cause acute renal failure, including hemolytic uremic syndrome, nephritic syndrome, and severe dehydration. Most children with acute renal failure are admitted to a pediatric intensive care unit. A urinary tract infection would not cause any of the listed symptoms. Bladder exstrophy is a congenital defect discovered at birth. Vesicoureteral reflux is a backflow of urine from the bladder to the kidneys.

Which instructions would the nurse provide to the family of a child who has undergone a hypospadias repair? (Select all that apply.) a. Avoid tub baths until the catheter is removed. b. Notify the primary healthcare provider if there is blood in the urine. c. The child should avoid the straddling position with play. d. It is important that the catheter be left in place. e. Notify the primary healthcare provider if the child goes more than 30 minutes without urine output.

Answer: a. Avoid tub baths until the catheter is removed; c. The child should avoid the straddling position with play; d. It is important that the catheter be left in place. Feedback: The nurse should discuss with the family the importance of leaving the catheter in place, notifying the primary healthcare provider if the child goes more than 1 hour without urine output, notifying the primary healthcare provider if the child avoids the straddling position with play, and avoiding baths until the catheter is removed. It is normal to see blood-tinged urine for several days after surgery.

For what condition does the nurse taking care of a 5-year-old newly diagnosed with Crohn disease teach the parents that their son may be at risk later? a. Cancer b. Malabsorption c. Atresia d. Hepatitis

Answer: a. Cancer Feedback: The risk of cancer is greatly increased for the child diagnosed with Crohn disease. Symptoms of Crohn disease include cramped abdominals followed by diarrhea, fever, anorexia, growth failure or weight loss, general malaise, and joint pain. The risks for malabsorption, atresia, and hepatitis do not increase in clients with Crohn disease.

A community health nurse is educating a high school class about sexually transmitted infections (STIs). Which information should be included in the presentation? a. Chlamydia can be asymptomatic. b. Ejaculation must occur for gonorrhea to be transmitted. c. A condom will protect teenagers from getting herpes. d. Intercourse is the only means of transmitting STIs.

Answer: a. Chlamydia can be asymptomatic. Feedback: Abstinence from all forms of sexual contact will protect a teenager from getting an STI. Many people have Chlamydia without knowing it, as it can be asymptomatic. A condom does not always protect a teenager from getting herpes, because the herpes lesion might not be covered by the condom and the condom might break. Gonorrhea can be transmitted without ejaculation.

Which intervention would not be included in the preoperative plan of care for an infant with an omphalocele? a. Push the exposed abdominal contents back into the abdomen. b. Administer intravenous fluids. c. Assess for signs of other congenital anomalies. d. Care for the infant in a radiant warmer.

Answer: a. Push the exposed abdominal contents back into the abdomen. Feedback: Care of an infant with an omphalocele (congenital malformation where abdominal contents herniate through the umbilical cord covered by a translucent sac) is aimed at protection of abdominal contents. Aggressive attempts at replacing abdominal contents can lead to numerous problems, including increased abdominal pressure, impaired respiratory status, and bowel perforation. The goals should be to protect the infant from hypothermia, replace fluids, prevent infection, and look for other associated anomalies.

Which intervention would be appropriate when a nurse is caring for a child with acute postinfectious glomerulonephritis (APIGN)? a. Screen family members for strep throat. b. Offer a high-protein diet. c. Maintain strict fluid restriction. d. Monitor the child for hyperactivity.

Answer: a. Screen family members for strep throat. Feedback: Rationale: The child with APIGN should have a diet low in protein with no added salt. Family members should be checked for strep throat, and the child should be monitored for any neurological changes.

Which statement by the parent of an uncircumcised male infant would indicate the need for further teaching? a. "Frequent diaper changes are important." b. "I should forcibly retract the foreskin once a day." c. "Once the foreskin is retractable, it should be returned to its normal position after cleaning." d. "Harsh soaps should be avoided."

Answer: b. "I should forcibly retract the foreskin once a day." Feedback: The parent should never force the foreskin to retract, due to the fact that it may cause paraphimosis, which is where the foreskin cannot be returned to its normal position. Harsh soaps should be avoided. Frequent diaper changes are important to prevent irritation, and once the foreskin is retractable in early childhood, always return it to its normal position after cleaning.

The nurse is caring for a group of infants in the neonatal intensive care unit. Which infant would require preparation for immediate surgery due to risk of life-threatening respiratory distress? a. An infant with an umbilical hernia b. An infant with a diaphragmatic hernia c. An infant with a cleft palate d. An infant with gastroesophageal reflux

Answer: b. An infant with a diaphragmatic hernia Feedback: Gastroesophageal reflux, cleft palate, and umbilical hernia do not cause respiratory distress and are not considered surgical emergencies. A diaphragmatic hernia will cause the abdominal organs to extend into the chest, causing pressure on the thoracic cavity. Only 50% of afflicted infants survive.

In obtaining a nursing history on an 18-month-old with diarrhea, which questions might help to identify the cause of the problem? (Select all that apply.) a. Has the child taken diphenhydramine in the past week? b. Do any other family members have diarrhea? c. Has the child been on antibiotics recently? d. Does the child have any food sensitivities? e. Has the child traveled recently?

Answer: b. Do any other family members have diarrhea?; c. Has the child been on antibiotics recently?; d. Does the child have any food sensitivities?; e. Has the child traveled recently? Feedback: A complete history of the child with diarrhea is important to finding the cause. Questions should cover recent travel, medication use, exposures, and foods eaten. Diphenhydramine is an antihistamine that does not cause diarrhea. Similar symptoms in other family members suggest infectious etiology.

The nurse is preparing a pediatric client for a barium enema. Which diagnosis would support the need for this diagnostic test? a. Gastroschisis b. Intussusception c. Appendicitis d. Pyloric stenosis

Answer: b. Intussusception Feedback: Intussusception occurs when the intestine invaginates into another, causing pain with vomiting and passage of brown stool. The stools eventually can resemble currant jelly. Pyloric stenosis is a stenosis between the stomach and duodenum. Gastroschisis is a congenital defect where there is herniation of abdominal contents outside the abdominal wall. Appendicitis is an inflammatory process of the appendix

A child with nephrotic syndrome is placed on corticosteroids. About which side effects of corticosteroids should the nurse educate the family? a. Impaired balance b. Moon face c. Decreased appetite d. Hair loss

Answer: b. Moon face Feedback: Side effects of corticosteroids include moon face, increased hair growth, increased appetite, and mood swings. Impaired balance is not associated with corticosteroids.

An 8-year-old is admitted to the emergency department with an injury to the abdomen with single organ involvement. Which type of injury does the nurse suspect? a. High-velocity blunt trauma b. Sports-related trauma c. Penetrating trauma d. Bike-related trauma

Answer: b. Sports-related trauma Feedback: Sports-related abdominal trauma is often associated with a direct blow to the abdomen, and a single organ is usually injured. High-velocity blunt trauma usually involves multiple organs. Blunt trauma may not be apparent in penetrating traumas and would have to be assessed to determine what injury lies beneath the skin surface. Bike-related traumas can result in serious abdominal injuries.

Which condition in males would the nurse assess as a medical emergency? a. Cryptorchidism b. Testicular torsion c. Phimosis d. Inguinal hernia

Answer: b. Testicular torsion Feedback: Testicular torsion is a medical emergency and should be surgically repaired within 4 to 6 hours of onset. The testis rotates on its spermatic cord, obstructing blood supply. Inguinal hernia is when a portion of abdominal cavity protrudes into the groin. It is usually repaired after 3 months of age and is not considered emergent unless the hernia is incarcerated. Cryptorchidism is when a testicle is not descended. It is present at birth, and if the testicle does not descend by 1 to 2 years of age, it is repaired. Phimosis is when the skin around the glans of the penis is not retractable by young childhood.

Which condition in males would the nurse assess as a medical emergency? a. Cryptorchidism b. Testicular torsion c. Phimosis d. Inguinal hernia

Answer: b. Testicular torsion Feedback: Testicular torsion is a medical emergency and should be surgically repaired within 4-6 hours of onset. The testis rotates on its spermatic cord, obstructing blood supply. Inguinal hernia is when a portion of abdominal cavity protrudes into the groin. It is usually repaired after 3 months of age and is not considered emergent unless the hernia is incarcerated. Cryptorchidism is when a testicle is not descended. It is present at birth, and if the testicle does not descend by 1-2 years of age, it is repaired. Phimosis is when the skin around the glans of the penis is not retractable by young childhood.

A nurse is evaluating a parent performing a clean intermittent catheterization on a pediatric client. What would be an indication that the parent needs additional teaching? a. The parent uses a size 4 catheter for the procedure. b. The parent states that the child should be awakened once during the night to be catheterized. c. The parent uses a water-soluble lubricant to coat the end of the catheter. d. The parent uses gentle pressure to advance the catheter if resistance is met.

Answer: b. The parent states that the child should be awakened once during the night to be catheterized. Feedback: It is necessary to perform intermittent catheterization every 3-4 hours but not while the child is sleeping at night. A size 4 or 5 catheter is used for the procedure. A water-soluble lubricant, not Vaseline, is used. In males, the sphincter muscle located at the entrance to the bladder will cause resistance to the catheter, but with gentle pressure, the catheter will advance into the bladder.

Which client would the nurse suspect to have pyloric stenosis? a. A 7-month-old with choking episodes b. An 11-year-old with an olive-shaped abdominal mass c. A 5-week-old infant with projectile vomiting d. A 2-year-old with a harsh cough

Answer: c. A 5-week-old infant with projectile vomiting Feedback: The most likely incidence of pyloric stenosis is in a 2- to 8-week-old infant. The common symptoms are nonbilious projectile vomiting, irritability, and failure to gain weight.

Which intervention would the nurse include in the care of an infant following surgical repair of a cleft lip? a. Let the infant touch the suture lines as a means of self-comforting. b. Position the infant in the supine position for feedings to avoid aspiration. c. Administer pain medications as ordered. d. Use a special feeding device with shorter nipples.

Answer: c. Administer pain medications as ordered. Feedback: Special feeding devices with long nipples usually are used, and the infant is fed in the sitting position to avoid aspiration. Some soft restraints may be used to prevent the infant from touching the suture line.

A nurse is caring for an 11-month-old infant admitted for watery, green diarrhea; vomiting; and fever. He is diagnosed with gastroenteritis with no known source at this time. Which nursing diagnosis should be the highest priority? a. Altered Nutrition b. Anxiety related to hospitalization c. Fluid Volume and Electrolyte Imbalance d. Altered Family Coping

Answer: c. Fluid Volume and Electrolyte Imbalance Feedback: Fluid and electrolyte imbalance is a safety issue and a potentially life-threatening event. Although all of the diagnoses should be addressed, this takes precedence.

A nurse is discharging an infant after a pyloric stenosis repair. Which statement by the mother would indicate the need for further instructions prior to discharge? a. "I should call the doctor if my infant's temperature rises above 101 degrees." b. "I should fold the diaper down so it does not irritate the incision." c. "My infant's incision will need to be observed for redness, swelling, or discharge." d. "If my infant vomits, I should hold feedings for 6 hours."

Answer: d. "If my infant vomits, I should hold feedings for 6 hours." Feedback: It is normal for an infant to vomit occasionally after having surgery for pyloric stenosis. The infant should be fed on a normal feeding schedule. All other statements about checking the incision site, folding the diaper, and calling the doctor if there is a fever are true.

A nurse is assessing a 3-year-old for hemolytic uremic syndrome (HUS). Which assessment finding would be most characteristic of HUS? a. Fever b. Severe cough c. Diarrhea d. Oliguria

Answer: d. Oliguria Feedback: HUS is characterized by the classic triad of symptoms: thrombocytopenia, hemolytic anemia, and acute renal failure. Severe cough, fever, or diarrhea alone is not a sign of HUS. The problem usually is preceded by a urinary tract infection, upper respiratory infection, or acute gastroenteritis 1-2 weeks prior to the HUS.

What is a priority nursing diagnosis for the patient with nephrotic syndrome? A. Imbalanced nutrition: less than body requirements B. Disturbed body image C. Decreased cardiac output D. Acute pain

B. Disturbed body image Support for the patient, in terms of coping with an altered body image, is essential because there is often embarrassment and shame associated with the edematous appearance.

A patient with a ureterolithotomy returns from surgery with a nephrostomy tube in place. Postoperative nursing care of the patient includes A. encouraging the patient to drink fruit juices and milk B. forcing at least 2 to 3 L of fluids per day after nausea has subsided C. irrigating the nephrostomy tube with 10 mL of normal saline solution as needed D. notifying the physician if nephrostomy tube drainage is more than 30 mL per hour

B. forcing at least 2 to 3 L of fluids per day after nausea has subsided The nephrostomy tube is inserted directly into the pelvis of the kidney and attached to connecting tubing for closed drainage. The catheter should never be kinked, compressed, or clamped. If the patient complains of excessive pain in the area or if there is excessive drainage around the tube, check the catheter for patency. If irrigation is ordered, strict aseptic technique is required. No more than 5 mL of sterile saline solution is gently instilled at one time to prevent overdistention of the kidney pelvis and renal damage. Infection and secondary stone formation are complications associated with the insertion of a nephrostomy tube. Patients should drink 2 to 3 liters of fluid per day to reduce risk of infection and stone formation.

A child has a nasogastric (NG) tube after surgery for acute appendicitis. What is the purpose of the NG tube? A. Maintain electrolyte balance B. Maintain an accurate record of output C. Maintain gastric decompression D. Prevent infection

C. Maintain gastric decompression The NG tube is used to maintain gastric decompression until intestinal activity returns.The NG tube may adversely affect electrolyte balance by removing stomach secretions.NG drainage is one part of the child's output. The nurse would need to incorporate the NG drainage with other output.There is no relationship between the NG tube and prevention of the spread of infection.

An appropriate nursing recommendation for parents to assist in preventing recurrent respiratory infection would be to: A. Keep children away from other children B. See the pediatrician weekly C. Maintain strict hand washing D. Avoid all animals

C. Maintain strict hand washing

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? A External pacemaker B An electrophysiologic study (EPS) C Medications to prevent dysrhythmias D Implantable cardioverter-defibrillator (ICD)

D Rationale: An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? A Consume a diet low in fats. B Reduce total caloric intake. C Increase intake of olive oil. D The lipid levels are normal.

D Rationale: For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? A Exercise almost every day. B Avoid saturated fat intake. C Limit calories to daily limit. D Keep Hgb A1C less than 7%

D Rationale: If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? A Therapeutic lifestyle changes should become lifelong habits. B Physical activity is always started in the hospital and continued at home. C Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. D Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring.

D Rationale: In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or MI, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? A Unstable angina B Cardiac tamponade C Sudden cardiac death D Cardiac dysrhythmias

D Rationale: The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

Cardiopulmonary arrest

-agonal or guppy breathing, apnea, leading to asystole -Most often, CARDIAC ARREST IN CHILDREN IS THE RESULT OF A PRIMARY RESPIRATORY CAUSE. It is rare for a child or an infant to initially suffer a cardiac emergency. Usually, a child or an infant has a respiratory emergency first and then a cardiac emergency develops, IF the respiratory emergency is not caught and treated in time.

Indications for mechanical ventilation

-airway compromise- airway patency is in doubt or pt may be a risk for loosing patency-> ability to sneeze, gag, or cough compromised; aspiration is possible -respiratory failure- 2 types 1. Hypoxemic resp failure: PaO2 less than 60 mmHg in otherwise healthy individuals; insufficient O2 transfer into the blood 2. Hypercapnic resp failure: PaC02 greater than 50 mmHg in an other wise healthy individual; AKA "ventilatory failure" (insufficient Co2 removal); increased WOB, decreased ventilatory drive, or muscle fatigue -if you have to intimate an infant look at pinky finger for a reference-> just 1 mm of inflammation in an infants throat can make them not breath

Bronchiolitis/ Respiratory Syncytial Virus (RSV): Nursing care

-cardiopulmonary monitoring -monitor respiratory/cardiovascular status -cluster care so the child can rest -increase head of bed/crib -contact/droplet isolation; meticulous hand hygiene -chest percussion -promote hydration -support family -discharge planning

Asthma: Diagnostic Testing

-clinical diagnosis: H & P; symtoms, symptom patterns, severity, observations: -recurrent coughing spells (esp. at night) -family history of asthma/allergies -difficulty breathing -frequent respiratory infections -spirometry -pulse ox -ABG: decrease PaO2 and increased PaCO2 -elevated eosinophils -chest radiograph -allergy skin testing

Asthma: Collaborative Care

-clinical therapy: medications, hydration, education, support of family/child -main goal: maintain good long-term asthma control using the least amount of medications, reduce risk of adverse effects -3 goals: 1. Sleep through the night 2. Optimal school/work attendance 3. Optimal play and activity level

Laryngotracheobronchitis (croup viral): Treatment and nursing care

-cluster care to keep the child calm -cool mist humidification -cardiopulmonary/vital sign monitoring -give oxygen if Sp02 is less than 92% -sedatives are contradicted -give antipyretics, dexamethasone (0.6 mg/kg IM/IV/PO), corticosteroids -nebulized racemic epinephrine-> Effect onset within 30 minutes and lasts up to 2 hours (some effects may persist up to 4 hours); Observe at least 2 hours after administration; will need to be on cardiopulmonary monitor -Racemic epinephrine is contraindicated in epiglottitis -dont give antibiotics with this bc viral

Upper airway

-consists of: nose, oral cavity, pharynx, and larynx -function is to warm the air, humidify the air, filter the air, and for speech and smell

Lower airway

-consists of: trachea, bronchi, bronchioles, and alveoli -function is ventilation (to and fro movement of gas), and gas exchange (co2 and 2 exchanged between the pulmonary capillaries and alveoli) -if you are overdosing on opioids you're levels of co2 will increase (hypercapnia) and your respirations will decrease to 5 or 6 (hypoventilation)

Laryngotracheobronchitis (croup viral)

-croup: severe inflammation and obstruction of upper airway -Laryngotracheobronchitis: viral croup syndrome -viral invasion of upper airway; cause swelling (constriction) around the larynx, trachea, and bronchial passageways -hoarseness, inspiratory stridor (no wheezing), barking, cough, often worse at night, low-grade fever (101 or 102), respiratory distress, orthopnea (sitting up to breath) -happens usually from age 3 months-3 years -no drooling with this

Cystic Fibrosis: Preventing GI Blockage

-distal intestinal obstruction syndrome (DIOS)- ileum/colon in right lower quadrant: abdominal pain, distention, vomiting, failure to pass stools; right lower quadrant mass -chronic constipation -rectal prolapse -prevention/treatment: fiber and fluid, early aggressive laxative treatment with polyethylene glycol (miralax)- either oral of intestinal lavage; pro kinetic agents (Raglan)- enhance GI motility); enemas

Tonsillitis & Adenoiditis: Nursing interventions (preoperative)

-education is vitally important -routine preoperative care -reinforce food and fluid restrictions -no medications that can cause bleeding starting 10 days before surgery -age-appropraite explanations -encourage parents to stay with the child -prepare child for sights and sounds of surgery -allow child to play with equipment -provide reassurance -put transitional object in recovery room -prepare child for post-op experience (sore throat)

Short Term Asthma Control Medications

-give these during an asthma attack •Short-acting beta-2 agonists (SABA) (opens the airway) -Short-acting: Albuterol (Proventil, Ventolin). Take the albuterol FIRST to open the airway before taking other asthma meds! -Systemic: Epinephrine, Terbutaline (Brethine) -Anticholinergics (increase effectiveness of beta-2 agonists): Ipratropium bromide (Atrovent): Combivent (in combo w/ albuterol) •Systemic Corticosteroids (anti-inflammatory): Prednisone, prednisolone, methylprednisolone

Asthma: Nursing management

-high fowlers, give humidified o2 -monitor: respiratory and cardiovascular status; cough; vital signs; effectiveness of drug therapy; peak flow rates -do chest percussion -push fluids -cluster care -support family -educate family and child about allergens and irritant exposure control, avoid secondhand smoke, signs of early resp distress -review asthma action plan and communicate plan to school nurse

Pertussis (Whooping Cough)

-highly contagious and preventable with the immunization DTaP -major cause of mortality/morbidity in children throughout the world -signs and symptoms: initially presents the URI then progresses to paroxysmal cough and ends in a "whooping" sound when the person breaths in

Bronchiolitis/ Respiratory Syncytial Virus (RSV): Management

-humidified oxygen -iv fluids -contact and droplet isolation -NG tube feedings -nasal suctioning -chest percussion -mechanical ventilation -Albuterol nebs, antipyretics (no aspirin), Synagis monthly injections for high-risk children during RSV season (October - April) which are passive immunizations (antibodies not vaccine)

Cystic Fibrosis: Promoting optional nutrition

-i&o, daily weights -high protein, fat, and caloric diet -medium-chain triglycerides (MCT) oil -vitamin replacement of A, D, E, K -push fluids -salty foods -pancreatic enzymes with meals and snacks -goal is to achieve near-normal, well-formed stools, and adequate weight-gain

Ottis Media (OM)

-inflammation of the middle ear, sometimes accompanied by infection -common illness 6-24 months -eustachian tube- shorter, wider, more horizontal (makes kids at more risk for ear infection) -at risk: boys, daycare, allergies, second-hand smoke, cleft lip/palate, enlarge adenoids, down syndrome, formula-fed -preceded by upper respiratory/throat infection -having sippy cup in bed= chronic OM

Foreign Body Aspiration

-inhalation of any object into the respiratory tract -7% of deaths in children less than 4 -manifestations: coughing, choking, gagging, hoarse or muffled voice sounds, difficulty breathing, severe inspiratory stridor, wheezing, tachypnea, nasal flaring, retractions, irritability, decreased responsiveness -Nursing management: assessment, cardiopulmonary monitoring, remove foreign body

Peds respiratory system

-it changes until age 12 -children have a greater risk for a respiratory illness than adults -the upper airway is more prone to obstruction (smaller airway = greater resistance) -less alveolar surface area-> reduced area for gas exchange -more diaphragm breathing-> flexible chest reduces air intake -respiratory structures grow in size and distance from each other -immature infant respurory and neurologic system offers less efficient response to hypoxia and elevated PCO2 -chest wall stiffens with age- less retraction with distress -infants are obligate nasal breathers until 6 weeks of age -children have a shorter neck and smaller/shorter/narrower airways so they are more susceptible to airway obstruction and resp distress -their tongue is larger in proportion to the mount which can cause an obstructed airway in an unconscious child -their trachea is more pliable -they have smaller lung capacity and underdeveloped intercostal muscles and poor chest musculature = less pulmonary reserve, increased risk for lung function impairment -children rely on diaphragm for breathing = high risk for resp failure if the diaphragm is unable to contract

Respiratory distress

-it is increased rate, effort, and noise of breathing; requires much energy, but still in a state of compensation -Respiratory issues # 1 cause of hospitalization for children and teens ages 1 to 17 years -Respiratory distress leads to respiratory failure, then to cardiopulmonary arrest so early recognition and intervention is vital -early signs of resp distress: Tachypnea/ tachycardia, Intercostal retractions, Nasal flaring, Level of consciousness changes (irritability, confusion, anxiety, mild restlessness), Wheezing -late/severe signs of resp distress: bradypnea, bradycardia (Bradycardia in infants and children usually signifies a respiratory emergency!), Cyanosis, Apnea/ gasping respirations, Absent or very decreased breath sounds, Severely decreased level of consciousness (stupor, coma, lethargy, extreme restlessness), Suprasternal and supraclavicular retractions, head bobbing, seesaw respirations, expiratory grunts

Pertussis: Nursing care

-limit paroxysms (observe severity of cough, nutrition, rest, and recovery) -give antibiotic therapy -promote adequate nutrition -discuss vaccine (DTaP) -teach parents about hospitalization: droplet precaution; vital signs and oxygen saturation; hydration, nutrition, and fluids

Auscultation

-listen comparing one area to another -listen for equality of death sounds, diminished, or poor air exchange -abdominal breath sounds: fine crackles, wheezes (sibilant ronchi), ronchi (sonorous, coarse crackles), stridor -cough -prolonged inspiratory phase (stridor)= upper airway obstruction (croup, foreign body, epiglottis) -prolonged expiratory phase (wheeze)= lower airway obstruction (asthma, bronchiolitis, cystic fibrosis)

Respiratory assessment

-look at size, summery, and movement of the chest -infancy shape of chest is almost circular -less than 6-7 years respiratory movement is primarily abdominal or diaphragmatic -less than 60 breaths per min in small children is significant resp distress

OM: Diagnosis and Collaborative Care

-otoscopic exam: reddened building membrane -antibiotics: amoxicillin, augmentin, ceftriaxone, zithromax -surgical: myringotomy, tympanovstomy tubes -analgesics/antipyretics: acetaminophen, ibuprofen PO, auralgan otic drops (not after myringotomy_ -chronic infection: hearing and language test -keep immunizations up to date esp PCV

Tonsillitis & Adenoiditis: Nursing interventions (postoperative)

-place child in tonsillar position (semi-prone with head to side) -monitor airway, cardiopulmonary status, vital signs -cool humidified air via face mask -once the child is awake: semi-fowlers with head turned to the side -check for signs of hemorrhage (such as frequent swallowing- hallmark sign) -provide ice collar -avoid oral fluids until fully awake then only give clear, cool, non-citrus fluids (nothing red) -administer acetaminophen PRN -avoid throat cleaning and coughing (don't tell them to cough and deep breath after this surgery) -sore throat interventions -acetaminophen elixir -soft diet, push fluids -watch for bleeding: 1st 24 hrs; 7-10 days post surgery; frequent swallowing sign-> note the frequent swallowing to the surgeon immediately -report temp that is greater than 38.8 C (102 F)

Tonsillitis & Adenoiditis: Assessment findings

-red swollen tonsils -white or yellow patches -swollen lymph nodes -sore throat -decreased food or fluid intake -difficulty swallowing -difficulty breathing -disrupted breathing during sleep -fever and chills -diagnostic criteria: rapid strep, throat culture; inspection, clinical manifestations, x-rays, check for rash and spleen enlargement, CBC

Cystic fibrosis: Complications

-respiratory: chronic sinusitis; chronic moist productive cough; frequent respiratory infections; dyspnea; tachypnea; wheezing; decreased breath sounds; find crackles; clubbing fingers and toes; barrel chest; cyanosis -pulmonary hypertension, over inflation of the lungs -cardiovascular: rt-sided heart enlargement (cor pulmonale); heart failure; hyponatremia; circulatory collapse -Gastrointestinal system: clinical manifestations may appear at birth or may take years; vary in severity; blacked pancreatic ducts; no secretion of digestive enzymes; meconium ileus in a neonate (1st manifestations); large, frothy, bulky, greasy, foul-smelling stools; distended abdomen; abdominal cramping; weight loss; FTT, malnourishment, vitamin deficiency, liver cirrhosis; pot belly with wasted buttocks -Skin: salty taste to the skin; secretions excessive salt; basis for the "Sweat test"; loss of electrolytes: electrolyte imbalances -Reproductive systems: in males: decrease sperm motility, blocked vas deferent and in females: thick cervical mucous (difficulty conceiving) and pregnancy complications

Depth and location of retraction

-retractions: substernal, subcostal, intercostal, suprasternal, supraclavicular -effort: grunting, nasal flaring, seesaw respirations (chest wall retracts which abdomen rises with inspiration)/paradoxical breathing, head bobbing -the higher up the retractions = the more severe the illness is (the head bobbing while breathing is very bad)

How to use a peak flow meter

-slide indicator tab to bottom (zero) -stand up straight -take a deep breath -close your lips tightly around the mouthpiece -blow out as hard as you can -write down number where stopped -repeat 2 more times (blow 3 times total) -record highest of the 3 numbers -measure peak flow rate twice a day (morning and evening) -people with severe asthma should take readings: every morning, every evening, after an exertion, and before inhaling certain medications

Children are not just small adults

-the body surface area large for weight, making infants susceptible to hypothermia -all of the brain cells are present at birth_. myelination and further development of nerve fibers occur during the first year -their head is proportionally larger, making child susceptible to head injury -they have a higher metabolic rate, higher oxygen needs, and higher caloric needs -until puberty, percentage of cartilage in ribs is higher, making them more flexible and complaint -until about 10 years, there is a faster resp. rate, fewer and smaller alveoli, and less lung volume; total volume is proportional to weight (7-10 mL/kg) -up to about 4-5 years, diaphragm is primary breathing muscle; c02 is not effectively expired when child is distressed making child susceptible to metabolic acidosis -until puberty, bones are soft and more emily bent and fractured -muscle lack tone, power, and coordination during infancy; muscles are 25% of weight in infants versus 40% in adults -blood volume is weight dependent: 80 mL/kg -until later school age, proportion of body weight in water is larger, with more water in extracellular spaces; daily water exchange rate is much higher -until 12 to 18 months of age, kidneys int concentrate urine effectively and don't exert optimal control over electrolyte secretion and absorption -abdomen offers poor protection for the liver and spleen making them susceptible to trauma -untile late school age and adolescence, cardiac output is rate dependent not stroke volume dependent, making heart rate more rapid -short, narrow trachea in children under 5 yoa makes them susceptible to foreign body obstruction -tongue large relative to small nasal and oral airway passages -anterior fontanelle and open sutures are palpable up to about 18 months; posterior fontanelle closes between 2 and 3 months

Asthma

-the most common disease of childhood -chronic inflammatory condition of the lower airways -recurrent, reversible airways obstruction -inflammation, bronchospasm, and mucous -air trapped in alveoli causes hyperinflation -complex interplay of genetic (predisposition) and environmental factors (triggers) -triggers: tobacco smokes, dust mites, pets, mold, allergens, strong odors, food additives, physical exercise, weather changes, strong emotions, certain medications -people at risk: family history of asthma, allergies, eczema, black race -poor control causes airway remodeling

Epiglottis (bacterial croup)

-this is a true pediatric emergency -inflammation and edema of the epiglottis -bacterial, high fever -rapidly progressive course -classic symptoms: tripod position; dyspnea; drooling; dysphonia; distressed inspiratory effort; stridor/froglike croaking sounds -antibiotics are needed -dont inspect the throat with tongue blade-> don't put anything in the mouth bc any stimulation can cause the throat to close -may require immediate tracheotomy/endotracheal intubation -nursing interventions: reduce anxiety, cardiopulmonary monitoring, o2, no oral fluids, IV, antibiotics -prevention: H. influenza type B conjugate vaccine

How to use a nebulizer

-used for young children or for severe asthma episodes -adding moisture to the respiratory system helps clear secretions from the lungs -pt unable to hold the nebulizer mouthpiece in their mouth should use an aerosol mask •Connect the hose to an air compressor. •Fill the medicine cup with the prescription. •Attach the hose and mouthpiece to the medicine cup. •Can use the pipe or mask. •Place the mouthpiece in your mouth. •Breathe through your mouth until all the medicine is used. (Most times, this takes 10 to 15 minutes).

430. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3 year old child. The results indicate an area of induration measuring 10mm. The nurse should interpret these results as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test

1

The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement? 1. "A smoker has twice the risk of having a heart attack as a nonsmoker." 2. "I may try just cutting down first, because the damage has already been done." 3. "I don't think I want to quit because none of the effects are reversible anyway." 4. "I'm never going to start again because I can cut my risk of cardiovascular disease to zero within a year."

1. "A smoker has twice the risk of having a heart attack as a nonsmoker." Rationale: Cigarette smokers have twice the risk of having a myocardial infarction as a nonsmoker and have two to four times the risk of having sudden cardiac death. Smoking cessation will reduce its damaging effects on the cardiovascular system; however, its cessation will not cut the risk to zero in 1 year.

13. The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a male and wants to know if her new baby will likely have the disorder. Select the nurse's best response. 1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." 2. "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." 3. "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." 4. "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."

1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." There is a genetic component to Hirschsprung disease, so any future siblings are also at risk.

Which is the nurse's best response to a parent who asks what can be done at home to help a child with upper respiratory infection (URI) symptoms and a fever get better? 1. "Give your child small amounts of fluid every hour to prevent dehydration." 2. "Give your child Robitussin at night to reduce his cough and help him sleep." 3. "Give your child a baby aspirin every 4 to 6 hours to help reduce the fever." 4. "Give your child an over-the-counter cold medicine at night."

1. "Give your child small amounts of fluid every hour to prevent dehydration." It is essential that parents ensure their children remain hydrated during a URI. The best way to accomplish this is by giving small amounts of fluid frequently.

Which statement by the parent of a child using an albuterol inhaler leads the nurse to believe that further education is needed on how to administer the medication? 1. "I should administer two quick puffs of the albuterol inhaler using a spacer." 2. "I should always use a spacer when administering the albuterol inhaler." 3. "I should be sure that my child is in an upright position when administering the inhaler." 4. "I should always shake the inhaler before administering a dose."

1. "I should administer two quick puffs of the albuterol inhaler using a spacer." The parent should always give one puff at a time and wait 1 minute before administering the second puff.

Which statement indicates the parent needs further teaching on how to prevent his other children from contracting respiratory syncytial virus (RSV)? 1. "I should make sure that both my children receive Synagis (palivizumab) injections for the remainder of this year." 2. "I should be sure to keep my infected child away from his brother until he has recovered." 3. "I should insist that all people who come in contact with my children thoroughly wash their hands before playing with them." 4. "I should insist that anyone with a respiratory illness avoid contact with my children until well."

1. "I should make sure that both my children receive Synagis (palivizumab) injections for the remainder of this year." Synagis will not help the child who has already contracted the illness. Synagis is an immunization and a method of primary prevention.

The nurse is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? 1. "I will take this medication every day." 2. "I will take this medication every other day." 3. "I will take this medication until I feel better." 4. "I will take this medication only when I have pain."

1. "I will take this medication every day." Rationale: A single daily dose of 1 baby aspirin (low-dose aspirin) may be a component of the standard treatment regimen for the client after an MI. Aspirin helps prevent clotting and may prevent a thrombosis that could cause a second MI. If the client cannot tolerate aspirin, then another antiplatelet medication may be prescribed. The other three options are unacceptable because the benefit comes in taking the medication on a daily basis.

The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? 1. "I will walk for one-half hour daily." 2. "As long as I exercise I can eat anything I wish." 3. "My weight has nothing to do with this disease." 4. "It doesn't matter if my father had high cholesterol."

1. "I will walk for one-half hour daily." Rationale: Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Options 2 and 4 are incorrect because obesity and a diet high in fat can contribute to CAD. Option 4 is incorrect because genetic factors also contribute to CAD.

12. A 5-year-old is hospitalized with MCNS. The nurse obtains a history from the parents. Which statement by the parents is most consistent with MCNS? 1. "Our child missed 2 days of school last week because of a really bad cold." 2. "We went camping last week, and our child's legs were covered in bug bites." 3. "Our child came home from school a week ago due to vomiting and stomach cramps." 4. "Our child has a pet turtle but does not wash hands after playing with the turtle."

1. "Our child missed 2 days of school last week because of a really bad cold." An upper respiratory infection often precedes MCNS by a few days.

53. The parents of a child being evaluated for celiac disease ask the nurse why it is important to make dietary changes. Select the nurse's best response. 1. "The body's response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." 2. "When the child with celiac disease consumes anything containing gluten, the body responds by creating specials cells called villi, which leads to more diarrhea." 3. "The body's response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." 4. "The body's response to gluten causes damage to the mucosal cells, leading to malabsorbtion of water and hard, constipated stools."

1. "The body's response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." The inability to digest protein leads to an accumulation of an amino acid that is toxic to the mucosal cells and villi, leading to absorption problems.

The parent of a 4-month-old with cystic fibrosis (CF) asks the nurse what time to begin the child's first chest physiotherapy (CPT) each day. Which is the nurse's best response? 1. "Thirty minutes before feeding the child breakfast." 2. "After deep-suctioning the child each morning." 3. "Thirty minutes after feeding the child breakfast." 4. "Only when the child has congestion or coughing."

1. "Thirty minutes before feeding the child breakfast CPT should be done in the morning prior to feeding to avoid the risk of the child vomiting.

The parent of a child with influenza asks the nurse when the child is most infectious. Which is the nurse's best response? 1. "Twenty-four hours before and after the onset of symptoms." 2. "Twenty-four hours after the onset of symptoms." 3. "One week after the onset of symptoms." 4. "One week before the onset of symptoms."

1. "Twenty-four hours before and after the onset of symptoms." Influenza is most contagious 24 hours before and 24 hours after onset of symptoms.

47. The nurse receives a call from the mother of a 6-month-old who describes her child as sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Select the nurse's best response. 1. "Your infant will need to have some tests in the emergency room to determine if anything serious is going on." 2. "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency room for some tests and intravenous rehydration." 3. "Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula." 4. "Do not worry about the blood and mucus in the stool; it is not unusual for infants to have blood in their stools because their intestines are more sensitive."

1. "Your infant will need to have some tests in the emergency room to determine if anything serious is going on." The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation.

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level? 1. 90 mg/dL 2. 190 mg/dL 3. 290 mg/dL 4. 390 mg/dL

1. 90 mg/dL Rationale: The normal fibrinogen level is 180 to 340 mg/dL for men and 190 to 420 mg/dL for women. A critical value is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. For these reasons, the nurse should become most concerned with the level of 90 mg/dL.

Which child with asthma should the nurse see first? 1. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%. 2. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%. 3. A 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. 4. A 16-year-old who is speaking in short sentences, is wheezing, is sitting upright, and has an oxygen saturation of 93%.

1. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%. This child is exhibiting signs of severe asthma. This child should be seen first. The child no longer has wheezes and now has diminished breath signs.

Which child is at highest risk for requiring hospitalization to treat respiratory syncytial virus (RSV)? 1. A 2-month-old who was born at 32 weeks. 2. A 16-month-old with a tracheostomy. 3. A 3-year-old with a congenital heart defect. 4. A 4-year-old who was born at 30 weeks.

1. A 2-month-old who was born at 32 weeks. The younger the child, the greater the risk for developing complications related to RSV. This infant is at highest risk because of age and premature status.

28. Who is at the highest priority to receive the flu vaccine? 1. A healthy 8-month-old who attends day care. 2. A 3-year-old who is undergoing chemotherapy. 3. A 7-year-old who attends public school. 4. An 18-year-old who is living in a college dormitory.

1. A healthy 8-month-old who attends day care. Children between the ages of 6 and 23 months are at the highest risk for having complications as a result of the flu. Their immune systems are not as developed, so they are at a higher risk for influenza-related hospitalizations.

38. The nurse is caring for a newborn with esophageal atresia. When reviewing the mother's history, the nurse would expect to find which of the following? 1. A history of maternal polyhydramnios. 2. A pregnancy that lasted more than 38 weeks. 3. A history of poor nutrition during pregnancy. 4. A history of alcohol consumption during pregnancy.

1. A history of maternal polyhydramnios Maternal polyhydramnios is present because the infant cannot swallow and absorb the amniotic fluid in utero.

4. A 4-month-old female is brought to the emergency department with severe dehydration. Her heart rate is 198, and her blood pressure is 68/38. The infant's anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child's parents state that she has not "held anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of 94. Which of the following would the nurse expect to do immediately? 1. Administer a bolus of normal saline. 2. Administer a bolus of D10W. 3. Administer a bolus of normal saline with 5% dextrose added to the solution. 4. Offer the child an oral rehydrating solution such as Pedialyte.

1. Administer a bolus of normal saline. Dehydration is corrected with the administration of an isotonic solution, such as normal saline or lactated Ringer solution.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action? 1. Assist the client to get back into bed. 2. Report the chest pain episode to the health care provider. 3. Tell the client to stand still, and take the client's blood pressure. 4. Give a nitroglycerin (Nitrostat) tablet, and assist the client to the bathroom.

1. Assist the client to get back into bed. Rationale: The client is assisted back to bed to put the client at rest. The nurse can then measure vital signs and administer nitroglycerin that is prescribed for as-needed (PRN) use. The nurse should then report the chest pain episode to the health care provider. The nurse should not continue to assist the client into the bathroom because it places the client in danger because of continued myocardial oxygen demands.

The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? 1. Bilberry 2. Ginseng 3. Feverfew 4. Evening primrose

1. Bilberry Rationale: Bilberry is an herbal supplement that has been used to treat varicose veins. This supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease. Ginseng has been used to improve memory performance and decrease blood glucose levels in type 2 diabetes mellitus. Feverfew is used to prevent migraine headaches and to treat rheumatoid arthritis. Evening primrose is used to treat eczema and skin irritation.

A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check which? 1. Blood pressure 2. Cardiac rhythm 3. Respiratory rate 4. Peripheral pulses

1. Blood pressure Rationale: Assessing the blood pressure is a priority before administering nitroglycerin to determine the vasodilating effect of the medication and to monitor for a drop in blood pressure. Cardiac rhythm and respiratory rate are also important to assess after checking the blood pressure. Peripheral pulses do not need to be checked before administering this medication.

A client is scheduled for a dipyridamole thallium scan. The nurse should check to make sure that the client has not consumed which substance before the procedure? 1. Caffeine 2. Fatty meal 3. Excess sugar 4. Milk products

1. Caffeine Rationale: This test is an alternative to the exercise stress test. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline forms of medication. Aminophylline is the antagonist to dipyridamole.

A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? 1. Digoxin (Lanoxin) 2. Warfarin (Coumadin) 3. Amiodarone (Cordarone) 4. Potassium chloride (K-Dur)

1. Digoxin (Lanoxin) Rationale: Digoxin strengthens the heartbeat and decreases the heart rate. It is used in the treatment of heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat heart failure.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? 1. Flat 2. Semi-Fowler's 3. Trendelenburg's 4. Reverse Trendelenburg's

1. Flat Rationale: To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

3 zones that make up the asthma action plan

1. Green zone: no coughing, no chest tightness, no wheezing, no breathlessness, no waking up at night-> the pt is well and can go about his/her daily activities normally. However, some may still need to contrive with controller medication 2. Yellow zone: runny nose, coughing with phlegm, wheezing, breathlessness, chest tightness, waking up at night-> pt must start adjusting their inhaled medication according to prescribed doses. If he doesn't feel better after a few days, he must consult his doctor. 3. Red zone: medication is not helping, breathing is hard and fast, unable to count from one to 10 in one breath, asthma is rapidly getting worse, ribs show when breathing-> pt has reached the emergency stage. He/she must see a doctor immediately. Short acting bronchodilator is indicated

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. R 1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke. 4. Cigars or pipes are healthier than cigarette smoking. 5. Tobacco smoking increases a female's level of estrogen.

1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke. ationale: Tobacco use is a major risk factor for the development of coronary heart disease. Nicotine vasoconstricts the arteries causing a decrease in myocardial oxygen supply and an increase in demand. To successfully quit smoking, it is necessary to combine multiple strategies. Hypnosis is a complementary/alternative therapy smoking cessation strategy. Exposure to environmental tobacco (secondhand) smoke does increase the risk for the development of coronary heart disease. Cigar or pipe smokers have an increased risk for the development of coronary heart disease similar to environmental tobacco smoke. Tobacco smoking decreases estrogen levels in premenopausal women, increasing their risk of coronary heart disease.

The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 1. Obtain annual influenza vaccination. 2. Restrict fluid intake to 1000 mL per day. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week. 5. Take an extra dose of prescribed diuretic for swollen ankles.

1. Obtain annual influenza vaccination. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week. Rationale: Heart failure is a chronic illness and requires lifelong treatment with a focus on health maintenance. Annual influenza vaccination is recommended to prevent the flu. Avoiding dietary sodium will decrease intravascular volume. A weight gain of 3 or more pounds in a week most likely indicates fluid retention and needs to be reported to the health care provider. Fluid restrictions are not commonly prescribed for chronic heart failure although the client may be advised to monitor intake. The client should not change the dose of any medicine without talking with the health care provider.

Which would be appropriate nursing care management of a child with the diagnosis of mononucleosis? 1. Only family visitors. 2. Bedrest. 3. Clear liquids. 4. Limited daily fluid intake.

1. Only family visitors. Children with mononucleosis are more susceptible to secondary infections. Therefore, they should be limited to visitors within the family, especially during the acute phase of illness.

The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply. 1. Pink-tinged frothy sputum 2. Increase in respiratory rate 3. Ankle and lower leg swelling 4. Paroxysmal nocturnal dyspnea 5. Auscultation of crackles throughout the lungs

1. Pink-tinged frothy sputum 2. Increase in respiratory rate 5. Auscultation of crackles throughout the lungs Rationale: Left-sided heart failure can lead to pulmonary edema or acute decompensated heart failure (ADHF). Pink-tinged frothy sputum, an increase in respiratory rate (tachypnea), and auscultation of crackles throughout the lungs are signs of pulmonary edema caused by excess fluid accumulation in the alveoli. These signs need to be communicated to the health care provider because pulmonary edema requires immediate emergency treatment. Ankle and lower leg swelling and paroxysmal nocturnal dyspnea are clinical signs of chronic heart failure.

The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? 1. Provide a quiet and low-stimulus environment. 2. Encourage the family to come visit very frequently. 3. Encourage the client to call friends and relatives each day. 4. Recommend that the client watch TV as a constant diversion.

1. Provide a quiet and low-stimulus environment. Rationale: Chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain, such as emotional excitement. Each of the incorrect options increases the amount of client stimulation, which increases the risk of an anginal episode.

What does the therapeutic management of cystic fibrosis (CF) patients include? Select all that apply. 1. Providing a high-protein, high-calorie diet. 2. Providing a high-fat, high-carbohydrate diet. 3. Encouraging exercise. 4. Minimizing pulmonary complication. 5. Encouraging medication compliance.

1. Providing a high-protein, high-calorie diet. 3. Encouraging exercise 4. Minimizing pulmonary complication. 5. Encouraging medication compliance.

A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 1. Restricting the client's potassium intake 2. Encouraging the client to rest after meals 3. Administering the heparin with a 25-gauge needle 4. Holding the digoxin for a heart rate less than 60 beats per minute

1. Restricting the client's potassium intake Rationale: Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity. Digoxin should be held and the health care provider notified when the client's heart rate is less than 60 beats per minute, unless otherwise prescribed. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged.

The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? 1. Reviews the intake and output records for the last 2 days 2. Prescribes daily weights starting on the following morning 3. Changes the time of diuretic administration from morning to evening 4. Requests a sodium restriction of 1 g/day from the health care provider

1. Reviews the intake and output records for the last 2 days Rationale: Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? 1. Smoking history 2. Recent exposure to allergens 3. History of recent insect bites 4. Familial tendency toward peripheral vascular disease

1. Smoking history Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing which type of angina? 1. Stable 2. Variant 3. Unstable 4. Intractable

1. Stable Rationale: Stable angina, also known as exertional angina, is triggered by a predictable amount of effort or emotion. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and incapacitating, and is refractory to medical therapy.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? 1. Surgical tourniquet 2. Dry sterile dressings 3. Incentive spirometer 4. Over-the-bed trapeze

1. Surgical tourniquet Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client? 1. Take daily weights and monitor trends. 2. Encourage fluids to improve hydration. 3. Elevate the legs above the level of the heart. 4. Position supine with the head of the bed at 30 degrees.

1. Take daily weights and monitor trends. Rationale: BNP levels greater than 500 pg/mL indicate that heart failure is probable. Nursing measures are geared toward decreasing intravascular volume, decreasing preload, and decreasing afterload. Option 2 increases intravascular volume, and options 3 and 4 increase preload.

What would the nurse advise the parent of a child with a barky cough that gets worse at night? 1. Take the child outside into the more humid night air for 15 minutes. 2. Take the child to the ER immediately. 3. Give the child an over-the-counter cough suppressant. 4. Give the child warm liquids to soothe the throat.

1. Take the child outside into the more humid night air for 15 minutes. The night air will help decrease subglottic edema, easing the child's respiratory effort. The coughing should diminish significantly, and the child should be able to rest comfortably. If the symptoms do not improve after taking the child outside, the parent should have the child seen by a health-care provider.

The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? 1. Tall, peaked T waves 2. ST segment depressions 3. Shortened P-R intervals 4. Shortening of the QRS complex

1. Tall, peaked T waves Rationale: The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.

You obtain a history from the mother of a child with glomerulonephritis about how he became ill. Which of the following would you expect her to tell you she noticed? a) Headache, loss of appetite b) Dark brown urine c) Loss of weight, oliguria d) Diuresis and pallor

Dark brown urine Correct Explanation: Acute glomerulonephritis often presents with glomeruli bleeding, which is revealed as black or brown urine from old blood.

Omphalocele Defect location? Associated disorders?

Defect in the midline, covered by sac Associated disorders: Edwards syndrome (trisomy 18) -rocker bottom feet, micrognathia, low set ears, clench hands w/ overlapping fingers, prominent occiput Patau syndrome (trisomy 13) -rocker bottom feet, microphthalmia, microcephaly, cleft lip/palate, holoprosencephaly, polydactyly, cutis aphasia *Beckwith Wiedemann syndrome -big baby, big tongue, *ear pits, decreased glucose -WT2 mutation: Wilms tumor, macroglossia, organomegaly, hemihypertrophy

- diuresis up to 10L/day - urine is very dilute - BUN stops increasing - monitored for hypokalemia and hyponatremia

Diuretic phase

D (Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation and increase pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Analysis REF: 1324 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation b. To control pain c. To decrease respirations d. To improve oxygenation

Most urinary tract infections seen in children are caused by which of the following? a) Hereditary causes b) Intestinal bacteria c) Dietary insufficiencies d) Fungal infections

Intestinal bacteria Correct Explanation: Although many different bacteria may infect the urinary tract, intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. Hereditary and dietary concerns are not causes of urinary tract infections.

The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? 1. "I need to avoid pregnancy by taking oral contraceptives." 2. "I should avoid sitting in one position for long periods of time." 3. "I can finally stop wearing these support stockings that you gave me." 4. "I will be sure to maintain my fluid intake to at least four glasses daily."

2. "I should avoid sitting in one position for long periods of time." Rationale: Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.

The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? 1. "I will watch my weight gain." 2. "I will avoid walking for exercise." 3. "I will monitor my cholesterol intake." 4. "I will follow a low-fat, low-salt diet."

2. "I will avoid walking for exercise." Rationale: Lack of physical exercise contributes to the development of coronary artery disease, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Walking should be encouraged for 30 minutes a day. Watching weight gain, monitoring cholesterol and following a low-fat, low-salt diet are accurate statements

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching? 1. "I will avoid using table salt with meals." 2. "It is best to exercise once a week for an hour." 3. "I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations."

2. "It is best to exercise once a week for an hour." Rationale: Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthy habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that causes pain, and to take the medication at the first sign of chest discomfort.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? 1. "Smoking cessation is very important." 2. "Moving to a warmer climate should help." 3. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."

2. "Moving to a warmer climate should help." Rationale: Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

35. The nurse is caring for a newborn with a cleft lip and palate. The mother states, "I will not be able to breastfeed my baby." Select the nurse's best response. 1. "It sounds like you are feeling discouraged. Would you like to talk about it?" 2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" 3. "Although breastfeeding is not an option, you have the option of pumping your milk and then feeding it to your baby with a special nipple." 4. "We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration."

2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" Some mothers are able to breastfeed their infants who have a cleft lip and palate. The breast can help fill in the cleft and help the infant create suction.

Which is the nurse's best response to parents who ask what impact asthma will have on the child's future in sports? 1. "As long as your child takes prescribed asthma medication, the child will be fine." 2. "The earlier a child is diagnosed with asthma, the more significant the symptoms." 3. "The earlier a child is diagnosed with asthma, the better the chance the child has of growing out of the disease." 4. "Your child should avoid playing contact sports and sports that require a lot of running."

2. "The earlier a child is diagnosed with asthma, the more significant the symptoms." When a child is diagnosed with asthma at an early age, the child is more likely to have significant symptoms on aging.

30. A 6-week-old is admitted to the hospital with influenza. The child is crying, and the father tells the nurse that his son is hungry. The nurse explains that the baby is not to have anything by mouth. The parent does not understand why the child cannot eat. Which is the nurse's best response to the parent? 1. "We are giving your child intravenous fluids, so there is no need for anything by mouth." 2. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." 3. "When your child eats, he burns too many calories; we want to conserve the child's energy." 4. "Your child has too much nasal congestion; if we feed the child by mouth, the distress will likely increase."

2. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." Infants are at higher risk of aspiration because their airways are shorter and narrower than those of adults. An infant with influenza has lots of nasal secretions and coughs up mucus. With all the secretions, the infant is at an even higher risk of aspiration.

A school-age child has been diagnosed with strep throat. The parent asks the nurse when the child can return to school. Which is the nurse's best response? 1. "Forty-eight hours after the first documented normal temperature." 2. "Twenty-four hours after the first dose of antibiotics." 3. "Forty-eight hours after the first dose of antibiotics." 4. "Twenty-four hours after the first documented normal temperature."

2. "Twenty-four hours after the first dose of antibiotics." Children with strep throat are no longer contagious 24 hours after initiation of antibiotic therapy.

The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? 1. "Are you having any nausea?" 2. "Where is the pain located?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?"

2. "Where is the pain located?" Rationale: If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, precipitating factors, location, radiation, and quality. Although options 1, 3, and 4 may be components of the assessment, these would not be the initial assessment questions in this situation.

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response? 1. "There is nothing to worry about." 2. "You are concerned about losing your leg?" 3. "There are many people with the same problem, and they are doing just fine." 4. "You have the best health care provider in the city, and your health care provider will not let anything happen to you."

2. "You are concerned about losing your leg?" Rationale: The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client's concern and provides an opportunity for the client to further discuss the concern. Options 1, 3, and 4 are inappropriate because they provide false reassurance and do not address the client's concern.

The parent of a child with frequent ear infections asks the nurse if there is anything that can be done to help avoid future ear infections. Which is the nurse's best response? 1. "Your child should be put on a daily dose of Singulair (montelukast)." 2. "Your child should be kept away from tobacco smoke." 3. "Your child should be kept away from other children with otitis media." 4. "Your child should always wear a hat when outside."

2. "Your child should be kept away from tobacco smoke." Tobacco smoke has been proved to increase the incidence of ear infections. The tobacco smoke damages mucociliary function, prolonging the inflammatory process and impeding drainage through the eustachian tube.

To prevent further urinary tract infections in a preschooler, what measures would you teach her mother? a) Teach her to take frequent tub baths to clean her perineal area. b) Teach her to wipe her perineum front to back after voiding. c) Suggest she drink less fluid daily to concentrate urine. d) Encourage her to be more ambulatory to increase urine output

Teach her to wipe her perineum front to back after voiding. Correct Explanation: Escherichia coli can be easily spread from the rectum to the urinary meatus and cause infection if girls do not take precautions against this.

A (The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures, such as treatment with corticosteroids or immune globulin and nutritional support, to prevent or treat cirrhosis.)

The best chance of survival for a child with cirrhosis is: a. Liver transplantation. b. Treatment with immune globulin. c. Treatment with corticosteroids. d. Provision of nutritional support.

Which child is in the greatest need of emergency medical treatment? 1. 3-year-old who has a barky cough, is afebrile, and has mild intercostal retractions. 2. 6-year-old who has high fever, no spontaneous cough, and frog-like croaking. 3. 7-year-old who has abrupt onset of moderate respiratory distress, a mild fever, and a barky cough. 4. 13-year-old who has a high fever, stridor, and purulent secretions.

2. 6-year-old who has high fever, no spontaneous cough, and frog-like croaking. This child has signs and symptoms of epiglottitis and should receive immediate emergency medical treatment. The patient has no spontaneous cough and has a frog-like croaking because of asignificant airway obstruction.

Which child would benefit most from having ear tubes placed? 1. A 2-month-old who has had one ear infection. 2. A 2-year-old who has had five previous ear infections. 3. A 3-year-old whose sibling has had four ear infections. 4. A 7-year-old who has had two ear infections this year.

2. A 2-year-old who has had five previous ear infections. A 2-year-old who has had multiple ear infections is a perfect candidate for ear tubes. The other issue is that 2-year-old is at the height of language development, which can be adversely affected by recurrent ear infections.

Which laboratory result will provide the most important information regarding the respiratory status of a child with an acute asthma exacerbation? 1. CBC. 2. ABG. 3. BUN. 4. PTT.

2. ABG. The ABG gives the health-care team valuable information about the child's respiratory status: level of oxygenation, carbon dioxide, and blood pH.

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

2. Acute kidney injury Rationale: The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

40. The nurse is caring for a newborn who has just been diagnosed with tracheoesophageal atresia and is scheduled for surgery. Which of the following should the nurse expect to do in the preoperative period? 1. Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant. 2. Administer intravenous fluids and antibiotics. 3. Place the infant on 100% oxygen via a non-rebreather mask. 4. Have the mother feed the infant slowly in a monitored area, stopping all feedings 4 to 6 hours before surgery.

2. Administer intravenous fluids and antibiotics. Intravenous fluids are administered to prevent dehydration because the infant is NPO. Intravenous antibiotics are administered to prevent pneumonia be cause aspiration of secretions is likely.

Your client states " I came in here last year and got some medication for my bladder infection. It turned my urine orange but it helped. Can I get that again? What is the first action the nurse must take: 1. Get a urine sample immediately 2. Ask some more questions about her current and previous symptoms 3. Tell her that the drug that caused her urine to turn orange didn't correct the problem - it just made her feel better while the antibiotics healed the infection 4. Tell her she should have drunk more cranberry juice

2. Ask some more questions about her current and previous symptoms

A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first? 1. Check the client's vital signs. 2. Assist the client to sit or lie down. 3. Administer sublingual nitroglycerin. 4. Apply nasal oxygen at a rate of 2 L/min.

2. Assist the client to sit or lie down. Rationale: Chest pain is caused by an imbalance between myocardial oxygen supply and demand. During episodes of pain, the nurse first limits the client's activity and assists the client to a position of comfort, checks the vital signs, administers oxygen and medication according to protocol, and obtains a 12-lead electrocardiogram.

The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure? Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output. 1. Saving all chores for the end of the day 2. Avoiding exposure to either very hot or very cold weather 3. Eating large meals to reduce the work of the gastrointestinal tract 4. Keeping items stored above shoulder level to encourage exercise

2. Avoiding exposure to either very hot or very cold weather Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.

The nurse knows which of the following is a description of peritoneal dialysis when compared to hemodialysis? a) The child must go into a facility to get peritoneal dialysis. b) There are strict diet and fluid restrictions. c) The child can live a more normal lifestyle. d) Therapy is only 3 to 4 days per week.

The child can live a more normal lifestyle. Correct Explanation: The child can live a more normal lifestyle with peritoneal dialysis. This is a 7-day-a-week procedure, but there are less diet restrictions and more freedom with this type of procedure. Peritoneal dialysis can be performed at home.

teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.

The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). To obtain the specimen, the nurse will plan to

B (The posttransplantation course is complex. The leading cause of death after cardiac transplantation is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Congestive heart failure is not a leading cause of death. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1351 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

The leading cause of death after heart transplantation is: a. Infection. b. Rejection. c. Cardiomyopathy. d. Congestive heart failure.

The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner choice from the daily menu? 1. Beef ravioli, spinach soufflé, and Italian bread 2. Baked pollock, mashed potatoes, and carrot-raisin salad 3. Roasted chicken breast, brown rice, and stewed tomatoes 4. Beef vegetable soup, macaroni and cheese, and a dinner roll

2. Baked pollock, mashed potatoes, and carrot-raisin salad Rationale: Furosemide depletes potassium, and a client on digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia may make the client more susceptible to digoxin toxicity. The recommended daily intake for potassium is 2000 mg. Option 4 is not the best choice because beef vegetable soup contains a high amount of sodium and a minimal amount of potassium. Macaroni and cheese is also high in sodium and contains no potassium. Option 1 is not the best choice because beef ravioli is high in sodium and contains no potassium. Spinach soufflé is a good source of potassium but also contains sodium. Option 3 is not the best choice because roasted chicken breast, brown rice, and stewed tomatoes contain a minimal amount of potassium. Option 2 is the best choice because all three foods are high in potassium and low in sodium.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1. Strict bed rest for 24 hours 2. Bathroom privileges and self-care activities 3. Unrestricted activities because the client is monitored 4. Unsupervised hallway ambulation with distances less than 200 feet

2. Bathroom privileges and self-care activities Rationale: Upon transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1. Wear elastic stockings. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease, but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active? 1. Presence of ascites 2. Bilateral lung crackles 3. Jugular vein distention 4. Pedal edema bilaterally

2. Bilateral lung crackles Rationale: The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Breath sounds are an accurate indicator of left-sided heart function. Peripheral edema, jugular vein distention, and ascites can be present as a result of insufficiency of the pumping action of the right side of the heart.

56. Which of the following manifestations suggests that an infant is developing NEC? 1. The infant absorbs bolus orogastric feedings at a faster rate than previous feedings. 2. The infant has bloody diarrhea. 3. The infant has increased bowel sounds. 4. The infant appears hungry right before a scheduled feeding.

2. Bloody diarrhea can indicate that the infant has NEC.

A 3-year-old is brought to the ER with coughing and gagging. The parent reports that the child was eating carrots when she began to gag. Which diagnostic evaluation will be used to determine if the child has aspirated carrots? 1. Chest x-ray. 2. Bronchoscopy. 3. Arterial blood gas (ABG). 4. Sputum culture.

2. Bronchoscopy. A bronchoscopy will allow the physician to visualize the airway and will help determine if the child aspirated the carrot.

D (Staphylococcus viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1344 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

The most common causative agent of bacterial endocarditis is: a. Staphylococcus albus. b. Streptococcus hemolyticus. c. Staphylococcus albicans. d. Streptococcus viridans.

A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication? 1. Stroke 2. Cardiac arrest 3. High blood pressure 4. Urinary stone formation

2. Cardiac arrest Rationale: The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization, and move back during repolarization. Depolarization is responsible for cardiac contraction. Options 1, 3, and 4 are not associated with a low calcium level.

Which statement about pneumonia is accurate? 1. Pneumonia is most frequently caused by bacterial agents. 2. Children with bacterial pneumonia are usually sicker than children with viral pneumonia. 3. Children with viral pneumonia are usually sicker than those with bacterial pneumonia. 4. Children with viral pneumonia must be treated with a complete course of antibiotics.

2. Children with bacterial pneumonia are usually sicker than children with viral pneumonia. Children with bacterial pneumonia are usually sicker than children with viral pneumonia. Children with bacteria pneumonia can be treated effectively, but they require a course of antibiotics.

B (The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic murmur associated with ventricular septal defect is a loud, harsh, holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present. PTS: 1 DIF: Cognitive Level: Application REF: 1323 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis b. Patent ductus arteriosus c. Ventricular septal defect d. Coarctation of the aorta

The patient's peritoneal effluent appears cloudy.

The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider?

A (Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.)

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. The most appropriate nursing action is to: a. Notify the practitioner. b. Measure abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure.

C (If evidence is noted of cardiac tamponade (blood or fluid in the pericardial space constricting the heart), the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred until after the evaluation by the physician. PTS: 1 DIF: Cognitive Level: Analysis REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is caring for a child after heart surgery. What should she or he do if evidence is found of cardiac tamponade? a. Increase analgesia. b. Apply warming blankets. c. Immediately report this to the physician. d. Encourage the child to cough, turn, and breathe deeply.

B (In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents. PTS: 1 DIF: Cognitive Level: Analysis REF: 1337 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important objective to decrease this risk is to: a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure.

A (When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings of fluids should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.)

The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include: a. Elevating the head but giving nothing by mouth. b. Elevating the head for feedings. c. Feeding glucose water only. d. Avoiding suctioning unless the infant is cyanotic.

Joint pain

The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid?

B (The suture line should be cleansed gently after feeding. The child should be positioned on back or side or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.)

The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include: a. Arm restraints, postural drainage, and mouth irrigations. b. Cleansing of suture line, supine and side-lying positions, and arm restraints. c. Mouth irrigations, prone position, and cleansing of suture line. d. Supine and side-lying positions, postural drainage, and arm restraints.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds

2. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? 1. Dark, pink base 2. Deep and painful 3. Accompanied by very slight pain 4. Brown pigmentation of surrounding skin

2. Deep and painful Rationale: Arterial leg ulcers tend to be deep and painful. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has coloration consistent with peripheral arterial disease. Options 1, 3, and 4 are not characteristics of an arterial leg ulcer.

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? 1. Angry 2. Denial 3. Phobic 4. Obsessive-compulsive

2. Denial Rationale: Denial is the most common reaction when a client has a myocardial infarction or anginal pain. No angry behavior was identified in the question. Phobias and obsessive-compulsive disorders are mental health diagnoses.

A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact? 1. Most people love high-fat diets. 2. Denial is a common occurrence early after MI. 3. The client probably wants to belittle the opinion of the staff. 4. The client is not motivated to learn about heart disease at this time.

2. Denial is a common occurrence early after MI. Rationale: An early initial coping response following MI is denial. The nurse uses this knowledge of this common response in planning care for the client. Option 1 is an opinion and not based on information in the question. There is no evidence in the question to support options 3 and 4.

The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. 1. Defibrillation 2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion 5. Amiodarone (Cordarone)

2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion Rationale: The three goals of treatment for atrial fibrillation are ventricular rate control, prevention of embolic stroke, and restoration and maintenance of normal sinus rhythm. Digoxin (Lanoxin) is used for ventricular rate control. Warfarin (Coumadin) is used to decrease the risk of embolic stroke. Electrical cardioversion is used to restore normal sinus rhythm. Amiodarone (Cordarone) is used to treat ventricular tachycardia or ventricular fibrillation. Defibrillation is the treatment of choice for ventricular fibrillation.

A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client? 1. Providing a walker to aid in ambulation 2. Elevating the head of the bed to at least 45 degrees 3. Performing continuous monitoring of oxygen saturation 4. Placing an oxygen cannula at the bedside for use if needed

2. Elevating the head of the bed to at least 45 degrees Rationale: The management of dyspnea generally is directed toward alleviation of the cause. Symptom relief may be achieved or at least aided by placing the client at rest with the head of the bed elevated. Supplemental oxygen may be used but placing equipment at the bedside is not directly helpful. Monitoring of oxygen saturation detects early complications but does not help the client. Likewise, placing an oxygen cannula at the bedside for use would not help the client.

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care? 1. Place the client's bed in the Fowler's position. 2. Encourage the client to increase fluid intake. 3. Instruct the client to perform range-of-motion exercises of the extremities. 4. Hold regularly scheduled medications for 24 hours following the procedure.

2. Encourage the client to increase fluid intake. Rationale: Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in the Fowler's position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The regularly scheduled medications are needed to treat acute and chronic conditions.

The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next? 1. Ask whether the client wants to see a psychiatrist. 2. Explore with the client the sources of stress in life. 3. Reassure the client that everybody seems stressed these days. 4. Ask the client to write down a list of stressors to be evaluated at a later time.

2. Explore with the client the sources of stress in life. Rationale: The nurse should encourage the client to explore and verbalize stressors. Later, the nurse can teach the client strategies for coping with stress, such as the basic relaxation techniques of deep breathing, progressive muscle relaxation, and visualization. Option 1 could be construed as excessive or insulting and puts the client's feelings on hold. Option 3 ignores the client's concerns. Option 4 places further data collection of this area on hold.

A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action? 1. Get a prescription for pain medication. 2. Have the client stop and lie back down in bed. 3. Report the complaint to the health care provider. 4. Have the client continue to get out of bed and into a chair.

2. Have the client stop and lie back down in bed. Rationale: The pain associated with coronary artery disease is called angina pectoris, and it occurs because of myocardial tissue ischemia from insufficient blood flow to the heart. The nurse should first have the client stop the activity and lie back down to decrease the workload and oxygen demand on the heart. Options 1 and 3 can be done after ensuring that the client is resting. The pain medication that is likely to be prescribed is nitroglycerin, which is a coronary vasodilator. Option 4 is contraindicated and will worsen the pain and possibly lead to myocardial infarction.

The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen

2. Hyperactive bowel sounds in the area Rationale: Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm.

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? 1. I should take daily medication for life. 2. I should eat a diet that is low in fat and cholesterol. 3. I should continue to smoke to keep the metabolic rate high. 4. I should begin to exercise if diet is not sufficient to achieve weight loss.

2. I should eat a diet that is low in fat and cholesterol. Rationale: A diet that is low in fat and cholesterol helps slow the progression of CAD. This must be accompanied by regular exercise and cessation of smoking. If these measures are effective, the client may not need daily medication.

13. The nurse is teaching the family about MCNS and explains that the clinical manifestations are due to which of the following? 1. Chemical changes in the composition of albumin. 2. Increased permeability of the glomeruli. 3. Obstruction of the capillaries of the glomeruli because of antibody-antigen complex formation. 4. Loss of the kidney's ability to excrete waste and concentrate urine.

2. Increased permeability of the glomeruli. Increased permeability of the glomeruli in MCNS allows large substances such as protein to pass through and be excreted in the urine.

46. The nurse is caring for a 7-week-old scheduled for a pyloromyotomy in 24 hours. Which of the following would the nurse expect to find in the plan of care? 1. Keep infant NPO; begin intravenous fluids at maintenance. 2. Keep infant NPO; begin intravenous fluids at maintenance; place NGT to low wall suction. 3. Obtain serum electrolytes; keep infant NPO; do not attempt to pass NGT due to obstruction from pylorus. 4. Offer infant small frequent feedings; keep NPO 6 to 8 hours before surgery.

2. Keep infant NPO; begin intravenous fluids at maintenance; place NGT to low wall suction. In addition to giving fluids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach.

The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which? 1. Bend the leg at the hip. 2. Keep the ankles uncrossed. 3. Place two pillows under the knees. 4. Use the knee gatch on the bed controls.

2. Keep the ankles uncrossed. Rationale: A graft can become clotted from any form of pressure, which results in impaired blood flow through the graft. Positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees.

The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm

2. Limiting movement and abduction of the right arm Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment? 1. No stimulus, no stress 2. Low stimulus, low stress 3. High stimulus, low stress 4. Moderate stimulus, low stress

2. Low stimulus, low stress Rationale: An environment that is low stimulus and low stress is needed to decrease anxiety and metabolic demands for the client after MI. Nursing care is directed at promoting rest and assisting with activities of daily living. Option 1 cannot be provided, and options 3 and 4 are too high in stimulus to be therapeutic.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? 1. Moderately impaired, and the surgeon should be called 2. Normal, caused by increased blood flow through the leg 3. Slightly deteriorating, and should be monitored for another hour 4. Adequate from an arterial approach, but venous complications are arising

2. Normal, caused by increased blood flow through the leg Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.

How does the nurse interpret the laboratory analysis of a stool sample containing excessive amounts of azotorrhea and steatorrhea in a child with cystic fibrosis (CF)? The values indicate the child is 1. Not compliant with taking her vitamins. 2. Not compliant with taking her enzymes. 3. Eating too many foods high in fat. 4. Eating too many foods high in fiber.

2. Not compliant with taking her enzymes. If the child were not taking enzymes, the result would be a large amount of undigested food, azotorrhea, and steatorrhea in the stool. Pancreatic ducts in CF patients become clogged with thick mucus that blocks the flow of digestive enzymes from the pancreas to the duodenum. Therefore, patients must take digestive enzymes with all meals and snacks to aid in absorption of nutrients. Often, teens are noncompliant with their medication regimen because they want to be like their peers.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration

2. Pericardial friction rub Rationale: A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? 1. Suction the client vigorously. 2. Place the client in high-Fowler's position. 3. Begin assembling medications that are anticipated to be given. 4. Call the respiratory therapy department to request a ventilator.

2. Place the client in high-Fowler's position. Rationale: The client in pulmonary edema is placed in high-Fowler's position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. Assembling medications is useful but not critical to the immediate well-being of the client. The client may or may not need mechanical ventilation.

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? 1. Monitor oxygen saturation levels. 2. Place the client on a cardiac monitor. 3. Measure blood pressure every 4 hours. 4. Check capillary refill at least once per shift.

2. Place the client on a cardiac monitor. Rationale: The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? 1. Increased pulse rate 2. Relief of apprehension 3. Decreased urine output 4. Increased blood pressure

2. Relief of apprehension Rationale: Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressures, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when administered intravenously. Options 1, 3, and 4 are unrelated to the action of morphine sulfate.

A 5-year-old is brought to the ER with a temperature of 99.5°F (37.5°C), a barky cough, stridor, and hoarseness. Which nursing intervention should the nurse prepare for? 1. Immediate IV placement. 2. Respiratory treatment of racemic epinephrine. 3. A tracheostomy set at the bedside. 4. Informing the child's parents about a tonsillectomy.

2. Respiratory treatment of racemic epinephrine. The child has stridor, indicating airway edema, which can be relieved by aerosolized racemic epinephrine.

18. The nurse is caring for a 6-week-old infant with cerebral palsy and GER. After two hospital admissions for aspiration, the child is scheduled for a Nissen fundoplication. The nurse knows that this procedure involves which of the following? 1. The fundus of the stomach is wrapped around the inferior stomach, mimicking a lower esophageal sphincter. 2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. 3. The fundus of the stomach is wrapped around the middle portion of the stomach, decreasing the capacity of the stomach. 4. The fundus of the stomach is dilated, decreasing the likelihood of reflux.

2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. The Nissen fundoplication involves wrapping the fundus of the stomach around the inferior esophagus, creating a lower esophageal sphincter or cardiac sphincter.

The parent of a child with cystic fibrosis (CF) is excited about the possibility of the child receiving a double lung transplant. What should the parent understand? 1. The transplant will cure the child of CF and allow the child to lead a long and healthy life. 2. The transplant will not cure the child of CF but will allow the child to have a longer life. 3. The transplant will help to reverse the multisystem damage that has been caused by CF. 4. The transplant will be the child's only chance at surviving long enough to graduate college.

2. The transplant will not cure the child of CF but will allow the child to have a longer life. A lung transplant does not cure CF, but it does offer the patient an opportunity to live a longer life. The concerns are that, after the lung transplant, the child is at risk for rejection of the new organ and for development of secondary infections because of the immunosuppressive therapy.

The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe? 1. One half pound per day 2. Two pounds per week 3. Four pounds per week 4. Six pounds per week

2. Two pounds per week Rationale: Most people, including the mildly and moderately obese, can lose only about 2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due to protein and water loss alone.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the nurse best describe this type of anginal pain? 1. Stable angina 2. Variant angina 3. Unstable angina 4. Nonanginal pain

2. Variant angina Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. The data in the question is characteristic of a type of angina pain, and therefore, nonanginal pain is incorrect.

A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? 1. Prone with the head on a pillow 2. With the foot of the bed elevated 3. Reverse Trendelenburg's position 4. With the residual limb flat on the bed

2. With the foot of the bed elevated Rationale: During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

A (The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant's sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful. PTS: 1 DIF: Cognitive Level: Application REF: 1335 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands? a. Organize nursing activities to allow for uninterrupted sleep. b. Allow the infant to sleep through feedings during the night. c. Wait for the infant to cry to show definite signs of hunger. d. Discourage parents from rocking the infant

C (Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.)

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation

B, D, E (Feedings are usually instituted soon after a pyloromyotomy surgery, beginning with clear liquids and advancing to formula or breast milk as tolerated. IV fluids are administered until the infant is taking and retaining adequate amounts by mouth. Appropriate analgesics should be given around the clock because pain is continuous. Ice should not be applied to the incisional area as it vasoconstricts and would reduce circulation to the incisional area and impair healing.)

The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing (Select all that apply)? a. Nothing by mouth for 24 hours b. Administration of analgesics for pain c. Ice bag to the incisional area d. Intravenous (IV) fluids continued until tolerating fluids by mouth e. Clear liquids as the first feeding

The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. "I need to substitute eggs and milk for meat." 2. "I will eliminate all cholesterol and fat from my diet." 3. "I should routinely use polyunsaturated oils in my diet." 4. "I need to seriously consider becoming a strict vegetarian."

3. "I should routinely use polyunsaturated oils in my diet." Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hyperlipidemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.

41. The nurse is giving discharge instructions to the parents of a 1-month-old infant with tracheoesophageal atresia. The infant is being discharged with a GT. The nurse knows that the parents understand the discharge teaching when the mother states: 1. "I will give my baby feedings through the GT but place liquid medications in the corner of the mouth to be absorbed." 2. "I will flush the GT with 2 ounces of water after each feeding to prevent the GT from clogging." 3. "I will clean the area around the GT with soap and water every day." 4. "I will place petroleum jelly around the GT if any redness develops."

3. "I will clean the area around the GT with soap and water every day." The area around the GT should be cleaned with soap and water to prevent an infection.

52. The nurse is caring for a newborn with an anorectal malformation and has had a colostomy placed. The nurse knows that more education is needed when the infant's parent states which of the following? 1. "I will make sure the stoma is red." 2. "There should not be any discharge or irritation around the outside of the stoma." 3. "I will keep a bag attached to avoid the contents of the small intestine coming in contact with the baby's skin." 4. "As my baby grows, a pattern will develop over time, and there should be predictable bowel movements."

3. "I will keep a bag attached to avoid the contents of the small intestine coming in contact with the baby's skin." The colostomy contains stool from the large intestine; an ileostomy contains the very irritating stool from the small intestine.

Which statement by the parents of a toddler with repeated otitis media indicates they need additional teaching? 1. "If I quit smoking, my child may have a decreased chance of getting an ear infection." 2. "As my child gets older, he should have fewer ear infections, because his immune system will be more developed." 3. "My child will have fewer ear infections if he has his tonsils removed." 4. "My child may need a speech evaluation."

3. "My child will have fewer ear infections if he has his tonsils removed." Removing children's tonsils may not have any effect on their ear infection. Children who have repeated bouts of tonsillitis can have ear infections secondary to the tonsillitis, but there is no indication in this question that the child has a problem with tonsillitis.

14. The parents of a child hospitalized with MCNS ask why the last blood test revealed elevated lipids. What is the nurse's best response? 1. "If your child had just eaten a fatty meal, the lipids may have been falsely elevated." 2. "It's not unusual to see elevated lipids in children because of the dietary habits of today." 3. "Since your child is losing so much protein, the liver is stimulated and ends up making more lipids." 4. "Your child's blood is very concentrated because of the edema, so the lipids are falsely elevated."

3. "Since your child is losing so much protein, the liver is stimulated and ends up making more lipids." In MCNS, the lipids are truly elevated. Lipoprotein production is increased because of the increased stimulation of the liver hypoalbuminemia.

While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? 1. "Your doctor expects me to prepare you for this procedure." 2. "That's fine, if that's what you want. I'll call your health care provider." 3. "So you're saying that you want to talk to your health care provider?" 4. "I'm concerned with the way you've dismissed me. I know what I am doing."

3. "So you're saying that you want to talk to your health care provider?" Rationale: In option 3, the nurse uses the therapeutic communication technique of reflection to redirect the client's feelings back for validation. Option 1 is nontherapeutic and addresses the legal issue of performing a procedure when in fact the client is refusing. Although option 2 may seem appropriate, it does not reflect the client's feelings and doesn't provide an opportunity for the client to express feelings. Option 4 is clearly nontherapeutic because it focuses on the nurse's feelings rather than the client's feelings.

45. The nurse is caring for an 8-week-old infant being evaluated for pyloric stenosis. Which of the following statements made by the parents would be typical of a child with this diagnosis? 1. "The baby is a very fussy eater and just does not want to eat." 2. "The baby tends to have a very forceful vomiting episode approximately 30 minutes after most feedings." 3. "The baby is always hungry." 4. "The baby is happy in spite of getting really upset on spitting up."

3. "The baby is always hungry." Infants with pyloric stenosis are always hungry and often appear malnourished.

Which is the nurse's best response to the parent of an infant diagnosed with the first otitis media who wonders about long-term effects? 1. "The child could suffer hearing loss." 2. "The child could suffer some speech delays." 3. "The child could suffer recurrent ear infections." 4. "The child could require ear tubes."

3. "The child could suffer recurrent ear infections." When children acquire an ear infection at such a young age, there is an increased risk of recurrent infections.

48. The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The physician elects to give an enema. The parents ask the purpose of is the enema. Select the nurse's most appropriate response. 1. "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fix the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."

3. "The enema will help confirm diagnosis and has a good chance of fixing the intussusception." In most cases of intussusception in young children, an enema is successful in reducing the intussusception.

18. A 6-week-old male is scheduled for a hypospadias and chordee repair. The parent tells the nurse, "I understand why the hypospadias repair is necessary, but do they have to fix the chordee as well?" What is the nurse's best response? 1. "I understand your concern. Parents do not want their children to undergo extra surgery." 2. "The chordee repair is done strictly for cosmetic reasons that may affect your son as he ages." 3. "The repair is done to optimize his sexual function when he is older." 4. "This is the best time to repair the chordee because he will be having surgery anyway."

3. "The repair is done to optimize his sexual function when he is older." Releasing the chordee surgically is necessary for future sexual function.

38. A parent asks the nurse how it will be determined if their child has respiratory syncytial virus (RSV). Which is the nurse's best response? 1. "We will do a simple blood test to determine whether your child has RSV." 2. "There is no specific test for RSV. The diagnosis is made based on the child's symptoms." 3. "We will swab your child's nose and send that specimen for testing." 4. "We will have to send a viral culture to an outside lab for testing."

3. "We will swab your child's nose and send that specimen for testing." The child is swabbed for nasal secretions. The secretions are tested to determine if a child has RSV.

The nurse finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"? 1. "Would you like a mild sedative to help you relax?" 2. "Oh, don't worry, the weather is supposed to be sunny and clear today." 3. "Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" 4. "I can appreciate your concerns. Your family can stay with you tonight if you want them to."

3. "Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" Rationale: The nurse should initially respond to validate the client's concern and then should determine the client's knowledge level of the cardiac monitor. This gives the nurse an opportunity to do client education if necessary. Bringing in the family, friends, or chaplain as an alternate resource may provide the client with additional psychological support. Pharmacological interventions should be considered only if necessary. Minimizing the client's concern is a communication block.

24. A parent asks how to care for a child at home who has the diagnosis of viral tonsillitis. Which is the nurse's best response? 1. "You will need to give your child a prescribed antibiotic for 10 days." 2. "You will need to schedule a follow-up appointment in 2 weeks." 3. "You can give your child Tylenol every 4 to 6 hours as needed for pain." 4. "You can place warm towels around your child's neck for comfort."

3. "You can give your child Tylenol every 4 to 6 hours as needed for pain." Tylenol is recommended PRN for pain relief.

The parent of an infant with cystic fibrosis (CF) asks the nurse how to meet the child's increased nutritional needs. Which is the nurse's best suggestion? 1. "You may need to increase the number of fresh fruits and vegetables you give your child." 2. "You may need to advance your child's diet to whole cow's milk because it is higher in fat than formula." 3. "You may need to change your child to a higher-calorie formula." 4. "You may need to increase your child's carbohydrate intake."

3. "You may need to change your child to a higher-calorie formula." Often infants with CF need to have a higher-calorie formula to meet their nutritional needs. Infants may also be placed on hydrolysate formulas that contain medium-chain triglycerides.

A parent asks the nurse what will need to be done to relieve the constipation of her child who also has cystic fibrosis (CF). Which is the nurse's best response? 1. "Your child likely has an obstruction and will require surgery." 2. "Your child will likely be given IV fluids." 3. "Your child will likely be given MiraLAX." 4. "Your child will be placed on a clear liquid diet."

3. "Your child will likely be given MiraLAX." CF patients with constipation commonly receive a stool softener or an osmotic solution such as polyethylene glycol 3350 (MiraLAX) orally to relieve their constipation.

Which is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Urinary tract obstruction d. Severe dehydration

d. Severe dehydration The most common cause of acute renal failure in children is dehydration or other causes of poor perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.

Abdominal breathing is usually present in a child until what age? A. 2 B. 4 C. 6 D. 9

C. 6

how often to evaluate venipuncture insertion site

every 15-30 min after the procedure to assess for bleeding

Normal for children under age 6 to have:

•Abdominal breathing, faster respiratory rate than older children and adults •Airways more prone to obstruction •Smaller airway = increased airway resistance •Less pulmonary reserve •Tonsils, adenoids, epiglottis, tongue are proportionately larger in young children •Trachea is shorter and angle of right bronchus at bifurcation more acute (steeper) than adult - easier to cause damage while suctioning; easier to aspirate objects; right lung most common site of lower airway obstruction because of sloped angle

* Chronic Renal Failure TX pharmacological

- antihypertensives - diuretics - erythropoietin - phosphate binders - vitamin D

kidney transplantation candidates

- younger than 70 & have a life expectancy of at least 2 more years

Cystic Fibrosis: Diagnosis

-presentation: meconium ileus; FTT; respiratory infections; intussusception -newborn screening, genetic marker -positive sweat test- GOLD STANDARD: chloride (normal less than 40 meq/L, highly suggestive of CF 50-60 meq/L, diagnostic greater than 60 meq/L) -pancreatic enzymes: collection of stool specimen to assess trypsin and lipase, trypsin absent in 80% of children with CF

The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided? 1. Catsup 2. Sherbet 3. Cooked cereal 4. Leafy green vegetables

1. Catsup Rationale: Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet all are low in sodium. Clients with heart failure should monitor sodium intake.

* colony count of urine that indicates infection

100,000 colonies/ml of urine

Which would be an early sign of respiratory distress in a 2-month-old? 1. Breathing shallowly. 2. Tachypnea. 3. Tachycardia. 4. Bradycardia.

2. Tachypnea. Tachypnea is an early sign of distress and is often the first sign of respiratory illness in infants.

The clients urine sample returned positive for glucose, ketones, and protein. The likely cause is: 1. Infection 2. Kidney failure 3. Diabetes 4. Dehydration

3. Diabetes

Check the chart for the most recent blood potassium level.

After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first?

Which urinalysis result do you recognize as an abnormal finding? A. pH of 6.0 B. WBC count: 9/hpf C. Amber yellow color D. Specific gravity of 1.025

B. WBC count: 9/hpf Normal WBC levels in urine are below 5/hpf, and levels exceeding this indicate inflammation or urinary tract infection.

Check the patient's blood pressure.

During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?

circulation of pt's blood with dialysate fluid, removing excess body fluid

hemodialysis

**Continent urinary diversion pouch nursing implications:

- *client will need to self cath every 4-6 hours

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? 1. The boot has not yet dried. 2. The boot is controlling leg edema. 3. The boot is impairing venous return. 4. The boot has been applied too tightly.

4. The boot has been applied too tightly. Rationale: An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? 1. The ulcer has a pale-colored base. 2. The ulcer is deep, with even edges. 3. The ulcer has little granulation tissue. 4. The ulcer has a brownish or "brawny" appearance.

4. The ulcer has a brownish or "brawny" appearance. Rationale: Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema. Therefore, options 1, 2, and 3 are incorrect descriptions.

MJ has had chronic lower urinary tract infections for many years. Now they have found bladder cancer and the MD recommends a cystectomy. When doing pre-op teaching the client states decides the client is well informed about the surgery when the client states: 1. I can't believe I have to have my kidney removed 2. Will I have to wear a colostomy bag? 3. I can't believe how they can take a part of my ileum for collection 4. Will I need a catheter after this?

4. Will I need a catheter after this?

62. A chloride level greater than _____________________ is a positive diagnostic indicator of cystic fibrosis (CF).

60 mEq/L. The definitive diagnosis of CF is made when a child has a sweat chloride level >60 mEq/L. A normal chloride level is <40 mEq/L.

A (Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous pressure, and as a result decreasing edema. Heart size is decreased by digoxin. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1332 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

A beneficial effect of administering digoxin (Lanoxin) is that it: a. Decreases edema. b. Decreases cardiac output. c. Increases heart size. d. Increases venous pressure.

C (Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function. PTS: 1 DIF: Cognitive Level: Analysis REF: 1332 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

A clinical manifestation of the systemic venous congestion that can occur with congestive heart failure is: a. Tachypnea. b. Tachycardia. c. Peripheral edema. d. Pale, cool extremities.

D (Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

A common, serious complication of rheumatic fever is: a. Seizures. b. Cardiac arrhythmias. c. Pulmonary hypertension. d. Cardiac valve damage.

A (Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas and avocados are high in fiber.)

A high-fiber food that the nurse could recommend for a child with chronic constipation is: a. Popcorn. b. Muffins. c. Pancakes. d. Ripe bananas.

B (The mechanism of action of histamine receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. Preventing reflux and hematemesis and increasing gastric acid production are not the modes of action of histamine receptor antagonists.)

A histamine receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with gastroesophageal reflux. The purpose of this is to: a. Prevent reflux. b. Reduce gastric acid production. c. Prevent hematemesis. d. Increase gastric acid production.

Monitor the urine output after the procedure.

A hospitalized patient with a decreased glomerular filtration rate is scheduled to have an intravenous pyelogram (IVP). Which action will be included in the plan of care?

A (Polyarthritis is swollen, hot, red, and painful joints. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler's nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis. PTS: 1 DIF: Cognitive Level: Analysis REF: 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

A major clinical manifestation of rheumatic fever is: a. Polyarthritis. b. Osler's nodes. c. Janeway spots. d. Splinter hemorrhages of distal third of nails.

D (Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.)

A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition? a. Protein intolerance b. Fat malabsorption c. Parasitic infection d. Bacterial gastroenteritis

Which statement by an 8-year-old child with asthma indicates that she understands the use of a peak expiratory flow meter? A. "My peak flow meter can tell me if an asthma episode might be coming, even through I might still be feeling okay." B. "When I do my peak flow meter, it works best tif I do three breaths without pausing in between breaths." C. "I always start with the meter reading about halfway up. That way I don't waste any breath." D. "If I use my peak flow meter every day, I will not have an asthma attack

A. "My peak flow meter can tell me if an asthma episode might be coming, even through I might still be feeling okay."

An adolescent twitch asthma says she heard her doctor say making was her trigger. the adolescent asks the nurse what that means. The nurse explains to the adolescent that a trigger is: A. A substance or condition that brings on an asthmatic episode. B. The term for narrowing of the airways during an asthmatic episode C. Another way to describe asthma D. The rapid breathing associated with an asthma attack

A. A substance or condition that brings on an asthmatic episode.

Which nursing diagnosis is a priority in the care of a patient with renal calculi? A. Acute pain B. Deficient fluid volume C. Risk for constipation D. Risk for powerlessness

A. Acute pain Urinary stones are associated with severe abdominal or flank pain. Deficient fluid volume is unlikely to result from urinary stones, and constipation is more likely to be an indirect consequence rather than a primary clinical manifestation of the problem. The presence of pain supersedes powerlessness as an immediate focus of nursing care.

A patient is admitted to the hospital with severe renal colic caused by renal lithiasis. What is your first priority in management of the patient? A. Administer opioids as prescribed. B. Obtain supplies for straining all urine. C. Encourage fluid intake of 3 to 4 L/day. D. Keep the patient NPO in preparation for surgery.

A. Administer opioids as prescribed. Pain management and patient comfort are primary nursing responsibilities when managing an obstructing stone and renal colic.

What instructions would you give to a patient being treated with nitrofurantoin (Furadantin, Macrodantin)? A. Avoid sunlight and wear sunscreen or use protective clothing. B. Avoid concurrent consumption of calcium-containing products. C. Take the medication concurrently with vitamin C. D. Do not be alarmed if urine is red.

A. Avoid sunlight and wear sunscreen or use protective clothing. Nitrofurantoin carries a significant drug alert. The patient should be taught to avoid sunlight, use sunscreen, and wear protective clothing. The patent should notify the health care provider if fever, chills, cough, chest pain, dyspnea, rash, or numbness or tingling of fingers or toes develop.

15. Narcotic administration should be administered carefully in patients with acute pancreatitis related to potential for a. respiratory depression. b. narcotic dependency. c. sphincter of Oddi dysfunction. d. allergic reaction.

ANS: C All narcotics should be used carefully because of the potential of sphincter of Oddi dysfunction, although recent studies show that no single agent is contraindicated. Respiratory failure related to adult respiratory distress syndrome is a risk factor with severe pancreatitis. Narcotic dependency should not be a concern with acute pancreatitis. While patients should always be assessed for allergies, this is not the primary concern.

Which instruction should be provided to the parents of an infant with gastroesophageal reflux? a. "Feed every 4-5 hours to prevent overfeeding." b. "Place in a seated position for 10 minutes after feedings." c. "Elevate the head of the crib at all times." d. "Burp every 3-4 ounces with feeding."

Answer: c. "Elevate the head of the crib at all times." Feedback: Management of gastroesophageal reflux includes administering small, frequent feedings and burping every 1-2 ounces. Elevating the head of the bed and holding the infant upright for 30 minutes after feeding help minimize the reflux. Putting the infant in a seated position can increase the pressure on the abdomen, causing reflux to increase.

The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? A Delegated to the primary care provider B Discussed along with other physical activities C Avoided because it is embarrassing to the patient D Accomplished by providing the patient with written material

B Rationale: Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

Posterior urethral valves S/S? Tx?

Baby with anterior midline mass (bladder) Anuria in 1st couple days of life Tx: catheterize then surgery

You are caring for a client who has undergone a total colectomy with ileoanal reservoir. With this type of bowel diversion, how will the client accomplish bowel elimination?

By evacuating the bowel on a commode in the usual way; however, the feces will still be liquid

When taking the nursing history of a child with cystic fibrosis, what piece of information about the child's newborn period would the nurse expect the mother to report? A. The child required resuscitation in the delivery room B. Labor was longer than 24 hrs C. The child had a meconium ileus D. Labor was less than 4 hours

C. The child had a meconium ileus

Intussusception S/S? Dx & Tx?

Colicky ABD pain & current jelly stools RUQ: sausage shaped mass Dx & Tx: barium enema

ibuprofen (Motrin)

During assessment of a patient with decreased renal function, which of these medications taken by the patient at home will be of most concern to the nurse?

C (Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.)

For what clinical manifestation should a nurse be alert when suspecting a diagnosis of esophageal atresia? a. A radiograph in the prenatal period indicates abnormal development. b. It is visually identified at the time of delivery. c. A nasogastric tube fails to pass at birth. d. The infant has a low birth weight.

You are assessing a 1-month-old breastfed baby. You ask the child's mother about his bowel movements and she describes them to you. Given the child's diet and stage of development, which of the following types of stool should you most expect?

GOLDEN YELLOW

B (Blood loss and extracellular fluid loss are two of the most frequent causes of hypovolemic shock in children. Myocardial infarction is rare in a child; if it occurred, the resulting shock would be cardiogenic, not hypovolemic. Anaphylaxis results in distributive shock from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease tends to contribute to hypervolemia, not hypovolemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1355 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

One of the most frequent causes of hypovolemic shock in children is: a. Myocardial infarction. b. Blood loss. c. Anaphylaxis. d. Congenital heart disease.

Meckel's diverticulum

Path: vitelline duct remnant S/S: painless, intermittent hematochezia < 2 years old < 2% of population 2X males: females 2 feet ileocecal valve 2 inches Dx: Technicium-99 (Teenager: CT scan better than tech-99)

Cardiopulmonary Monitoring

SpO2 in children - should be ≥ 95% (unless underlying cyanotic congenital heart condition). SpO2 reading less than 94% in a child indicates hypoxemia (low oxygen in the blood). -using high levels of o2 could lead to excessive pulmonary blood flow and CHF in these children

A (Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth, but is usually not apparent until ages 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.)

The earliest clinical manifestation of biliary atresia is: a. Jaundice. b. Hepatomegaly. c. Vomiting. d. Absence of stooling.

Scrambled eggs, English muffin, and apple juice

The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful?

may experience blood-tinged urine and urinary frequency.

The nurse informs the patient undergoing cystoscopy that following the procedure, the patient _________________

C (Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.)

The viral pathogen that frequently causes acute diarrhea in young children is: a. Giardia organisms. b. Shigella organisms. c. Rotavirus. d. Salmonella organisms.

have 2000 to 3000 mL of fluid a day.

To prevent the recurrence of renal calculi, the nurse teaches the patient to _____________

disturbed body image related to change in body function.

Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of __________

D (Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic shock b. Cardiogenic shock c. Hypovolemic shock d. Anaphylactic shock

Place the patient on a cardiac monitor.

When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first?

A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurse's best response should be that the: a. blood pressure will stabilize. b. the child will have more energy. c. urine will be free of protein. d. urinary output will increase.

d. urinary output will increase. An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in urinary output.

Long term asthma control medications

•These medications need to be taken regularly to be effective; most on a daily basis. •Long-acting beta-agonists (LABA) (bronchodilation; generally used in conjunction with inhaled corticosteroids): o Salmeterol (Serevent) o Formoterol (Foradil, Perforomist) •Theophylline (Theodur, Slo-Bid) (oral methylxanthines, result in bronchodilation) - only occasionally used to control asthma •Mast cell inhibitors/ stabilizers (histamine antagonist; anti-inflammatory; inhaled anti-asthmatic agents) o Cromolyn sodium (Intal) o Nedocromil (Tilade) •Leukotriene receptor antagonists (anti-inflammatory; oral anti-asthmatic agents) o Zafirlukast (Accolate) o Montelukast (Singulair) o Zileuton (Zyflo) •Inhaled Corticosteroids (anti-inflammatory; reduce swelling of the airways; the most effective medications for controlling asthma when taken regularly; wash mouth after every time you use it to prevent thrush): o Beclomethasone (Qvar) o Budesonide (Pulmicort) o Flunisolide (Aerobid) o Fluticasone (Flovent) o Mometasone (Asmanex) o Triamcinolone (Azmacort) •Immunotherapy (subcutaneous, therapeutic antibody) Omalizumab injection (XOLAIR) - dosed every 2 to 4 weeks -Rinse mouth after using inhalers containing corticosteroids to prevent thrush (examples: Qvar, Pulmicort, Symbicort, Flovent, Advair).

Cardiac rhythm

A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?

Catheterization technique and schedule

A patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching?

The nurse is reinforcing teaching with the caregiver of 5-year-old twins regarding urinary tract infections (UTI's). The caregiver is puzzled about why her daughter has had three urinary tract infections but her son has had none. She reports that their diets and fluid intake is similar. Which of the following statements would be accurate for the nurse to tell this mother? a) "It is unlikely that your daughter is practicing good cleaning habits after she voids." b) "Girls need more vitamin C than boys to keep their urinary tract healthy, so your daughter may be deficient in vitamin C." c) "A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily." d) "The position of the urethra in girls makes girls more susceptible than boys to UTI's."

"A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily." Correct Explanation: Many different bacteria may infect the urinary tract, and intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. The female urethra is shorter and straighter than the male urethra, so it is more easily contaminated with feces.

Asthma: Clinical Manifestations

-frequent coughing (esp. at night) -coughing that gets worse after active play or changes in weather -prolonged expiration -expiratory wheezing -shortness of breath (short panting phrases) -increased work of breathing (tachypnea, nasal flaring, retractions, use of accessory muscles) -chest tightness -poor exercise tolerance

The nurse is preparing a 7-year-old girl for discharge after treatment for nephrotic syndrome. Which instructions would the nurse include in the discharge teaching plan for the parents? a) "Let's meet with the dietitian and plan some meals." b) "Here is some written information from the dietitian." c) "She must severely restrict her sodium intake." d) "She should try to avoid protein."

"Let's meet with the dietitian and plan some meals." Correct Explanation: Consultation with a dietitian would be most helpful for meal planning because so many of children's favorite foods are high in sodium. Restricting sodium may not be necessary if the child is not edematous; in addition, the statement does not teach. Protein-rich snacks should be encouraged. The nurse needs to provide the parents with specific instructions, assistance, and resources in addition to simple written instructions.

A female client complains of a stinging sensation when she urinates. You suspect a urinary tract infection (UTI). Which of the following are additional signs and symptoms of UTI that you should assess for in this client?

- Foul-smelling urine - Blood in the urine - Back pain

Glomerulonephritis Nursing Interventions:

- check proteinuria, specific gravity, and color of urine - weigh client daily - ** if client has hypertension, check BP every 2-4 hours - * teach client to perform dipstick urine test to monitor for protein

* Chronic Renal Failure Diagnostics:

- elevated blood sugar & triglycerides - increased serum potassium level - decreased hemoglobin and hematocrit

*Chronic Renal Failure Diet TX

- lose weight - restrict protein - fluid restriction 600-1000 ml - sodium and potassium restriction

PEDs respiratory rates

-1 year: RR: 25-40 -3 years: RR: 20-30 -6 years: RR: 16-22 -10 years: RR: 16-20 -17 years: RR: 12-20

Treatment of Pharyngitis

-10 day course of PCN - must take all. -No longer contagious after 24 hours on antibiotic. -Complications -> rheumatic fever/ rheumatic heart disease; post-streptococcal glomerulonephritis

Pharynigitis

-2 types: 1. Viral Pharyngitis 2. Streptococcal Pharyngitis

You are caring for a client who is confined to bed following back surgery. Which of the following measures should you take to promote normal bowel elimination in this client?

-Encourage the client to defecate soon after she feels the urge to do so. -Encourage the client to drink eight to ten 8-ounce glasses of water daily. -Perform range-of-motion (ROM) exercises with the client to promote peristalsis.

Tonsillitis & Adenoiditis: Collaborative and Supportive care

-PCN (full 10-day course) for group A beta hemolytic streptococcus infection -viral infection: supportive care: rest, fluids, comforting foods, saltwater, gargles, cool-air humidifier, lozenges, treat pain, and fever -surgery: removal of tonsils and adenoids (T & A) if the respiratory/swallowing status is compromised or for difficult to treat conditions

Symptoms of hypoxia

-RAT (early) BED (late) R: restlessness A: anxiety T: tachycardia/tachypnea B: bradycardia E: extreme restlessness D: dyspnea (severe) -specific for peds: F: feeding difficulty I: inspiratory stridor N: nares flare E: expiratory grunting S: sternal retractions

Cystic Fibrosis: Medications

-aerosol bronchodilators to open airways -mucolytic enzyme (dornase alfa (Pulmozyne)- to thin mucous to cough it out easier -mist of hypertonic saline- to clear thick mucous from lungs -ibuprofen- slows lung function decline -inhaled antibiotics (tobramycin)- antimicrobial for chronic lung infections (pseudomonas aerugionosa) -oral and IV antibiotics- treat and suppress infections -pancreatic enzymes to help digest food -vitamins A, D, E, K/ fat soluble vitamins

Cystic Fibrosis: Maintaining respiratory function

-aerosol treatment- thin secretions, keep them mobile: bronchodilators, dornase alfa (DNase), hypertonic saline -NEVER give cough syrups or codeine -aggressive chest PT/oscillating est 3-4 X a day (30 minutes before meals and at bedtime) to increase sputum expectoration -breathing exercises -physical exercise important adjunct -lung transplantation

Cystic Fibrosis

-genetic illness (autosomal recessive; if both parents are carriers, then there is a 25% chance with each conception)- dysfunction of the exocrine glands -obstruction caused by thick, viscous mucous -leads to irreversible lung damage -more common in caucasians -one of the most common causes of childhood death -complex disorder: affects multiple organ systems, esp. respiratory and GI

Bronchiolitis/ Respiratory Syncytial Virus (RSV)

-lower: respiratory infection: acute obstruction and inflammation of the bronchioles-> bronchioles become narrowed or occluded as a result of inflammatory process, edema, mucous, and cellular debris dog bronchioles, and alveoli -can cause viral pneumonia -leading cause of hospital admission (infants less than 12) -at risk: preterm, chronic disease states/respiratory conditions (like tracheostomy or bronchopulmonary dysplasia), immunocompromised -obstructed airways, impaired gas exchange, hypoxemia, hypercapnia, atelectasis, respiratory failure -long-term effects: wheezing, asthma, COPD -RSV season: October-April -no antibiotics for this -just 1 mm of swelling will cause them to lose 50% of their airway -transmission is droplet and contact -symptoms last 4-6 days; most recover in 1-2 weeks -

Foreign Body Aspiration: Teaching and Prevention

-no small hard candies, hot dogs, raisins, popcorn or nuts until ages 3 or 4 -no latex ballons -cut food into small pieces -no running, jumping, or talking with food in mouth -inspect toys for small parts -keep coins, earrings, marbles out of reach

Respiratory distress treatment

-oxygenation -positioning -fluids -medications: bronchodilator, anti-inflammatory, corticosteriods

Ottis Media (OM) Clinical Manifestation

-sudden piercing pain; irritability -fever (as high as high as 104 F (40 C)) -vomiting, diarrhea -rubbing or pulling at the ear -rolling head from side to side -night awakening -muffled hearing; permanent hearing loss -speech development problems -reddened, bulging membrane

The patient has noticed clots in the urine.

A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which information given by the patient is most important to report to the health care provider?

A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.) 1) palpating the bladder height. 2) obtaining a clean-catch urine specimen. 3) performing a bladder scan. 4) asking the patient about his recent voiding history. 5) encouraging the patient to consume cranberry juice daily. 6) inserting a straight catheter to measure residual urine.

1) Palpating the bladder height. 3) Performing a bladder scan. 4) Asking the patient about his recent voiding history.

Excess fluid volume related to low serum protein levels

A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient?

433. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? SELECT ALL THAT APPLY. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear mask at all times when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1 6

How asthma obstructs airflow

1) Muscles outside of the airways tighten or constrict (bronchospasm) 2) Inside of airway becomes inflamed 3) Thick fluid or mucous enters the airway; the airway then becomes swollen or plugged by mucous Can get air in, but not out. Air trapped in alveoli, hyperinflation (prolonged expiratory phase)-> wheezing -dry cough = first sign

You are caring for an ambulatory male client and would like to promote normal urination in him. Which of the following actions should you take?

1) Stand outside the bathroom door while he is urinating and ask, "Are you okay?" occasionally to reassure him of your presence in case he needs you. 2) Allow the client to stand and use the toilet in the bathroom for urination, if he is able, instead of using the urinal in bed. 4) Encourage the client to drink eight to ten 8-ounce glasses of fluid daily. 5) Excuse visitors from the room when discussing care related to urination. 6) Explain to the client that the diuretic he will be taking will cause him to urinate more often.

Correct order to pulmonary hygiene

1) bronchodilator nebulizer (albuterol) 2) expectorant nebulizer (hypertonic saline) 3) mucolytic nebulizer (dornase alfa) 4) chest physiotheraphy with postural drainage (or oscillating vibration vest) 5) cough (or cough assist device) 6) suctioning 7) inhaled antibiotics

62. The nurse is interviewing the parents of a 6-year-old who has been experiencing constipation. Which of the following could be a causative factor? Select all that apply. 1. Hypothyroidism. 2. Muscular dystrophy. 3. Myelomeningocele. 4. Drinks a lot of milk. 5. Active in sports.

1, 2, 3, 4. 1. Hypothyroidism can be a causative factor in constipation. 2. Weakened abdominal muscles can be seen in muscular dystrophy and can lead to constipation. 3. Myelomeningocele affects the innervation of the rectum and can lead to constipation. 4. Excessive milk consumption can lead to constipation. 5. Activity tends to decrease constipation and increase regularity.

Place a bedside commode near the patient's bed.

A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?

1000

A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL.

The patient describes allergies to shellfish and penicillin.

A patient who is scheduled for an intravenous pyelogram (IVP) gives the nurse the following information. Which information has the most immediate implications for the patient's care?

Your client says I just seem to always be in the bathroom to urinate. My urine looks like clear water. The nurse ask the client all of the following except: 1. Are you keeping your blood sugars under control? 2. How much do you urinate each time you go? 3. How much fluid do you drink during the day? 4. Do you have any burning or pain when you urinate?

1. Are you keeping your blood sugars under control?

A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? 1. Chest pain 2. Urge to cough 3. Warm, flushed feeling 4. Pressure at the insertion site

1. Chest pain Rationale: The client is taught before cardiac catheterization to immediately report chest pain or any unusual sensations. The client is taught that a warm, flushed feeling may accompany dye injection, occasional palpitations may occur, and the urge to cough may occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site.

Your client is on strict bedrest precautions post spinal surgery. She is allowed to have the head of the bed up only 30 degrees. The pt. now needs to urinate but is unable for any of the following reasons, except: 1. Dehydration post-op 2. Position restrictions 3. She can not be turned due to spinal surgery 4. Anesthetic agents lingering in the body

1. Dehydration post-op

Mrs. K, and 85 year old widow, has food poisoning and complains of N/V and inability to keep any food or fluids down for 2 days. She has poor skin turgor and dry mucus membranes . She had liquid stools initially and now has had no stools for 24 hours. The nurse realizes that it is important to do which of the following assessments first to better understand Mrs. K's hydration status. 1. Have her estimate her intake and output for the last 48 hours 2. Check postural vital signs 3. Check her BUN and Creatinine 4. Have her tell you what is in her refrigerator

1. Have her estimate her intake and output for the last 48 hours

The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate? 1. Headache is a common side effect of nitrates. 2. Fever usually accompanies coronary artery disease. 3. Acetaminophen potentiates the therapeutic effects of nitrates. 4. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.

1. Headache is a common side effect of nitrates. Rationale: Headache occurs as a side effect of nitrates. Acetaminophen may be given before nitrates to prevent headaches or to minimize the discomfort from the headaches. Option 2 is incorrect. Options 3 and 4 are unrelated to the data in the question.

The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development? 1. Hypokalemia 2. Hypernatremia 3. Hypochloremia 4. Hypercalcemia

1. Hypokalemia Rationale: The nurse assesses the client's serum laboratory results for hypokalemia. The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect.

A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure? 1. Lung crackles, peripheral edema, and weight gain 2. Confusion, decreasing level of consciousness, and aphasia 3. Respiratory distress, chest pain, and the use of accessory muscles 4. Flank pain with radiation to the groin, accompanied by hematuria

1. Lung crackles, peripheral edema, and weight gain Rationale: The client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse monitors the client for both pulmonary and peripheral symptoms, such as lung crackles, peripheral edema, and weight gain. Options 2 and 4 relate to disorders of the brain and kidney, respectively. Option 3 contains symptoms that occur with pulmonary embolism, which is not related to the subject of the question.

Insert retention catheter.

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first?

The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 3. Take a calcium supplement to lower blood pressure. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important

1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important Rationale: Primary hypertension is a condition that increases the risk of cardiovascular disease and renal disease. Home self-measure blood pressure monitoring should be done as prescribed to monitor the client's response to prescribed treatment. Follow-up appointments for blood pressure checks are also important to monitor the client's response to treatment. Sodium should be restricted as prescribed to prevent elevations in the blood pressure. Regular ophthalmoscopic examination is needed to detect retinal changes seen in hypertensive clients. The use of calcium supplements to lower blood pressure is not known and therefore is not recommended.

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which? 1. Vagus nerve to slow the heart rate 2. Vagus nerve to increase the heart rate 3. Diaphragmatic nerve to slow the heart rate 4. Diaphragmatic nerve to increase the heart rate

1. Vagus nerve to slow the heart rate Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? 1. Weigh self every morning before breakfast. 2. Sleep with the head elevated on only one pillow. 3. Adjust diuretic dose based on severity of peripheral edema. 4. Take additional digoxin (Lanoxin) if respiratory distress occurs.

1. Weigh self every morning before breakfast. Rationale: A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. The client should weigh himself or herself daily as a means of determining fluid balance and possible overload. The client should sleep with the head elevated as high as needed to prevent pulmonary congestion during sleep. The client should not self-adjust any medication dosages.

Match the grades of hepatic encephalopathy to the assessment findings. a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4

19. Stuporous, able to follow commands, marked confusion, slurred speech, liver flap present 20. Confusion, subtle behavioral changes, no liver flap 21. Coma, no liver flap 22. Drowsy, clear behavioral changes, liver flap present ---------------------------------------------------------------------------------- 19. ANS: C 20. ANS: A 21. ANS: D 22. ANS: B

rapid respirations.

A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for _________________

424. A 10 year old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats/minute 4. Respirations of 18 breaths/minute

2

428. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out. 3. The child has a low-grade fever and complains of a sore throat. 4. The child is leaning backward, supporting himself or herself with the hands and arms.

2

432. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the MOST APPROPRIATE nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a room with another child with RSV. 3. Leave the infant in the present room because RSV is not contagious. 4. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

2

a Fleet enema.

A patient with an elevated blood urea nitrogen (BUN) and serum creatinine is scheduled for a renal arteriogram. The nurse should question an order from radiology for bowel preparation with the use of

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

2. Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

the need to empty the bladder before treatment.

A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about ______________

A client with heart disease is describing his bowel function to you during a nursing history interview. Which of the following should you be concerned about?

2) The client has to rush to the toilet often to defecate. 3) The client often has to use the Valsalva maneuver when defecating. 4) There is bright red blood mixed with the stool. 6) The client frequently uses laxatives.

The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure. 1. Normal sinus 2. Atrial fibrillation 3. Sinus bradycardia 4. Ventricular fibrillation

2. Atrial fibrillation Rationale: Atrial fibrillation is characterized by no distinct P waves and an irregular ventricular response. In sinus bradycardia and normal sinus rhythm there will be clear distinct P waves and a regular ventricular rhythm. In ventricular fibrillation there are no clear P waves or QRS complexes.

You are assessing your client who lives in a nursing home. She states " I just get so constipated sometimes that I just try not to go in to the bathroom at all." As you continue your nutritional assessment you will ask about: 1. How much protein she is eating 2. Fluid intake 3. If she eats small frequent meals 4. What her sugar intake is on an average day

2. Fluid intake

425. The mother of an 8 year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen (Motrin IB) is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen. 2. Increase the frequency of ibuprofen. 3. Encourage the child to lie on the left side. 4. Encourage the child to lie on the right side.

4

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? 1. Tall, peaked T waves 2. ST-segment depression 3. Prolonged P-R interval 4. Widening of the QRS complex

2. ST-segment depression Rationale: In the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client may also exhibit a flat T wave. Options 1, 3, and 4 are cardiac findings noted in the client with hyperkalemia.

426. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1. Side or prone 2. Back or prone 3. Stomach with the face turned 4. Back rather than on the stomach

4

A school-age child has been diagnosed with nasopharyngitis. The parent is concerned because the child has had little or no appetite for the last 24 hours. Which is the nurse's best response? 1. "Do not be concerned; it is common for children to have a decreased appetite during a respiratory illness." 2. "Be sure your child is taking an adequate amount of fluids. The appetite should return soon." 3. "Try offering the child some favorite food. Maybe that will improve the appetite." 4. "You need to force your child to eat whatever you can; adequate nutrition is essential."

2. "Be sure your child is taking an adequate amount of fluids. The appetite should return soon." It is common for children to have a decreased appetite when they have a respiratory illness. The nurse is appropriately instructing the parent that the child will be fine by taking in an adequate amount of fluid.

27. The nurse is providing discharge instructions to the parents of a 10-year-old who had an appendectomy for a ruptured appendix 5 days ago. The nurse knows that further education is required when the child's parent states: 1. "We will wait a few days before allowing our child to return to school." 2. "We will wait 2 weeks before allowing our child to return to sports." 3. "We will call the pediatrician's office if we notice any drainage around the wound." 4. "We will encourage our child to go for walks every day."

2. "We will wait 2 weeks before allowing our child to return to sports." The child should wait 6 weeks before returning to any strenuous activity.

Position one hand flat at the costovertebral angle (CVA) and strike it with the other fist.

How will the nurse assess the flank area of a patient with pyelonephritis for tenderness?

The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client? 1. Shaves the front of the client's chest 2. Gives the client a device holder to wear around the waist 3. Teaches the client to rest as much as possible during the next 24 hours 4. Tells the client to cover the monitor in plastic wrap before taking a bath

2. Gives the client a device holder to wear around the waist Rationale: The nurse applies electrocardiographic (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor-sized monitor, which is worn around the chest or waist. The nurse would remind the client to maintain a normal schedule and to keep a diary of all activity and symptoms. The client should avoid activities that could interfere with the ECG recorder, such as using heavy machinery, electric shavers, hair dryers, or bathing or showering. Therefore, options 1, 3, and 4 are incorrect.

Which assessment is of greatest concern in a 15-month-old? 1. The child is lying down, has moderate retractions, low-grade fever, and nasal congestion. 2. The child is in the tripod position, has diminished breath sounds, and a muffled cough. 3. The child is sitting up and has coarse breath sounds, coughing, and fussiness. 4. The child is restless and crying, has bilateral wheezes, and is feeding poorly.

2. The child is in the tripod position, has diminished breath sounds, and a muffled cough. When children are sitting in the tripod position, they are having difficulty breathing. The child is sitting and leaning forward in order to breathe more easily. Diminished breath sounds are indicative of a worsening condition. A muffled cough indicates that the child has some subglottic edema. This child has several signs and symptoms of a worsening respiratory condition.

431. The mother of a hospitalized 2 year old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3

Meconium ileus S/S? Associated w/? Dx & Tx?

3 day old newborn that still has not passed meconium Consider Cystic Fibrosis (esp. if family hx) Dx & Tx: gastrograffin enema

Hirschsprung's disease S/S? Specific exam finding? Biopsy?

3 day old newborn that still has not passed meconium Digital rectal exam: explosion of feces Bx: shows no ganglia (gold standard)

11. One of your clients, a 5-year-old boy, sleeps restlessly at night in his hospital room and scratches around his anal area incessantly. You suspect that he might have pinworms. Which of the following actions should you take to confirm this suspicion? 1) Perform a fecal occult blood test at the patient's bedside. 2) Notify the primary care provider and prepare the patient for an x-ray of the abdomen. 3) Spread the child's buttocks while he is sleeping and visually examine for the worms. 4) Notify the primary care provider and prepare the patient for endoscopy by a gastroenterologist.

3) Spread the child's buttocks while he is sleeping and visually examine for the worms.

7. On reviewing information about glomerulonephritis, the nurse knows that which of the following children is at risk for developing the disease? 1. A 10-year-old recovering from viral pneumonia. 2. A 6-year-old with new-onset type 1 diabetes. 3. A 3-year-old who had impetigo 1 week ago. 4. A 5-year-old with a history of five UTIs in the previous year.

3. A 3-year-old who had impetigo 1 week ago. Impetigo is a skin infection caused by the streptococcal organism that is commonly associated with glomerulonephritis.

Which should the nurse instruct children to do to stop the spread of influenza in the classroom? 1. Stay home if they have a runny nose and cough. 2. Wash their hands after using the restroom. 3. Wash their hands after sneezing. 4. Have a flu shot annually.

3. Wash their hands after sneezing. It is essential that children wash their hands after any contact with nasopharyngeal secretions.

2. The nurse is caring for a 4- year-old who weighs 15 kg. At the end of a 10-hour period, the nurse notes the urine output to be 150 mL. What action does the nurse take? 1. The nurse notifies the physician because this urine output is too low. 2. The nurse encourages the patient to increase oral intake in order to increase urine output. 3. The nurse records the patient's urine output in the chart. 4. The nurse administers isotonic fluid intravenously to help with the rehydration process.

3. Recording the patient's urine output in the chart is the appropriate action because the urine output is within the expected range of 1-2 mL/kg/hr.

Which should be included in instructions to the parent of a child prescribed amoxicillin to treat an ear infection? 1. "Continue the amoxicillin until the child's symptoms subside." 2. "Administer an over-the-counter antihistamine with the antibiotic." 3. "Administer the amoxicillin until all the medication is gone." 4. "Allow your child to administer his own dose of amoxicillin."

3. "Administer the amoxicillin until all the medication is gone." It is essential that all the medication be given.

17. The nurse is caring for a newborn male with hypospadias. His parents ask if circumcision is an option. Which is the nurse's best response? 1. "Circumcision is a fading practice and is now contraindicated in most children." 2. "Circumcision in children with hypospadias is recommended because it helps prevent infection." 3. "Circumcision is an option, but it cannot be done at this time." 4. "Circumcision can never be performed in a child with hypospadias."

3. "Circumcision is an option, but it cannot be done at this time." It is usually recommended that circumcision be delayed in the child with hypospadias because the foreskin may be needed for repair of the defect.

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? 1. Decrease in pedal edema 2. High urine output during the day 3. Weight gain of 2 to 3 pounds in a few days 4. Cough accompanied by other signs of respiratory infection

3. Weight gain of 2 to 3 pounds in a few days Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in daytime voiding is expected while on diuretic therapy (Lasix). A cough as a result of respiratory infection does not necessarily indicate that heart failure is exacerbating.

427. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

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429. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the MOST APPROPRIATE nursing action? 1.Tell the mother that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the health care provider and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face.

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C, D, E (High-fiber foods include whole grain breads, bran pancakes, and raw carrots. Unrefined (brown) rice is high in fiber but white rice is not. Raw fruits, especially those with skins or seeds, other than ripe banana or avocados are high in fiber.)

A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber (Select all that apply)? a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots

Teach the patient how to perform Kegel exercises.

A 62-year-old asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan?

Costovertebral tenderness

A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)?

The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement? 1. "Recuperation after cardiac surgery is generally slower for older people." 2. "It's important to get out of bed every day, even if tired or weak at first." 3. "Fatigue, discomfort, and lack of appetite occur more commonly with older people and may last for 2 to 5 weeks." 4. "A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control."

4. "A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control." Rationale: Clients generally increase activity by beginning a simple walking program, starting with distances of 400 feet twice daily and gradually increasing the distance until able to walk 1¼ mile (usually at the end of the second week). Exercise has physiological and psychological benefits. The statements made in options 1, 2, and 3 are correct.

16. The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Select the nurse's best response. 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until the constipation resolves." 2. "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." 3. "Daily bowel irrigations will help your child maintain regular bowel habits." 4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much of your child's bowel is involved."

4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much of your child's bowel is involved." The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached.

The client is now 4 days post op from abdominal surgery. The surgeon orders and NG to low intermittent suction and the pt. may only chew on a cup of ice chips per shift. The likely reason for this is: 1. Pt must be returning to surgery 2. Paralytic ileus 3. He is assessing for bleeding in the gut 4. Gastric decompression for bloating

4. Gastric decompression for bloating

Which physical findings would be of most concern in an infant with respiratory distress? 1. Tachypnea. 2. Mild retractions. 3. Wheezing. 4. Grunting.

4. Grunting. Grunting is a sign of impending respiratory failure and is a very concerning physical finding.

48. What should be the nurse's first action with a child who has a high fever, dysphagia, drooling, tachycardia, and tachypnea? 1. Immediate IV placement. 2. Immediate respiratory treatment. 3. Thorough physical assessment. 4. Lateral neck radiographs..

4. Lateral neck radiographs.. This child is exhibiting signs and symptoms of epiglottitis and should be kept as comfortable as possible. The child should be allowed to remain in the parent's lap until a lateral neck film is obtained for a definitive diagnosis.

A group of nurses is sitting around laughing about a joke when suddenly one jumps up and runs to the bathroom. Upon her return she states " I just can't hold my urine when I laugh anymore." She is likely experiencing: 1. Urge incontinence 2. Reflex incontinence 3. Functional incontinence 4. Stress incontinence

4. Stress incontinence

A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home? 1. The client can get the prescriptions filled. 2. The client can be self-sufficient at home without any help. 3. The client can independently dress and put on support hose. 4. The client can verbally describe the daily medications, doses, and times to be administered.

4. The client can verbally describe the daily medications, doses, and times to be administered. Rationale: Medication therapy is an essential part of the therapeutic regimen for treating heart failure. The client must have a clear understanding of which medications to take and when. Options 1 and 3 can be carried out with the assistance of someone else. Option 2 may not be realistic for this client.

The parents of a 5-week-old have just been told that their child has cystic fibrosis (CF). The mother had a sister who died of CF when she was 19 years of age. The parents are sad and ask the nurse about the current projected life expectancy. What is the nurse's best response? 1. "The life expectancy for CF patients has improved significantly in recent years." 2. "Your child might not follow the same course that the mother's sister did." 3. "The physician will come to speak to you about treatment options." 4. The nurse answers their questions briefly, listens to their concerns, and is available later after they've processed the information.

4. The nurse answers their questions briefly, listens to their concerns, and is available later after they've processed the information. The nurse's best intervention is to let the parents express their concerns and fears. The nurse should be available if the parents have any other concerns or questions or if they just need someone with whom to talk.

A child with severe cerebral palsy is admitted to the hospital with aspiration pneumo- nia. What is the most beneficial educational information that the nurse can provide to the parents? 1. The signs and symptoms of aspiration pneumonia. 2. The treatment plan for aspiration pneumonia. 3. The risks associated with recurrent aspiration pneumonia. 4. The prevention of aspiration pneumonia.

4. The prevention of aspiration pneumonia. The most valuable information the nurse can give the parents is how to prevent aspiration pneumonia from occurring in the future.

is much less likely to clot.

A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it

Obtain a midstream urine specimen for culture and sensitivity testing.

A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take?

Urine output is 20 mL/hr for 2 hours.

A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon?

Which individuals would the nurse identify as having the highest risk for CAD? A A 45-year-old depressed male with a high-stress job B A 60-year-old male with below normal homocysteine levels C A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels D A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

A Rationale: The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? A Oxygen, nitroglycerin, aspirin, and morphine B Oxygen, furosemide (Lasix), nitroglycerin, and meperidine C Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen D Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

A Rationale: The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? A White male B Hispanic male C African American male D Native American female

A Rationale: The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

A child is admitted to the hospital with asthma. Which assessment findings support this diagnosis? a. Nonproductive cough, wheezing b. Fever, general malaise c. Productive cough, rales d. Stridor, substernal retractions

A Asthma presents with a nonproductive cough and wheezing. Pneumonia appears with an acute onset, fever, and general malaise. A productive cough and rales would be indicative of pneumonia. Stridor and substernal retractions are indicative of croup.

A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV positive. Which induration size indicates a positive result for this child 48-72 hours after the test? a. 5 mm b. 10 mm c. 15 mm d. 20 mm

A Clinical evidence of a positive TST in children receiving immunosuppressive therapy, including immunosuppressive doses of steroids or who have immunosuppressive conditions, including HIV infection is an induration of 5 mm. Children younger than 4 years of age with: (a) other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutrition; (b) born or whose parents were born in high-prevalence (TB) regions of the world; (c) frequently exposed to adults who are HIV infected, homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized, or migrant farm workers; and (d) who travel to high-prevalence (TB) regions of the world are positive when the induration is 10 mm. Children 4 years of age or older without any risk factors are positive when the induration is 20 mm.

A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma? a. There is heightened airway reactivity. b. There is decreased resistance in the airway. c. The single cause of asthma is an allergic hypersensitivity. d. It is inherited.

A In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)-mediated response is inherited but is not the only cause of asthma.

The Heimlich maneuver is recommended for airway obstruction in children older than _____ year(s). a. 1 b. 4 c. 8 d. 12

A The Heimlich maneuver is recommended for airway obstruction in children older than 1 year. Younger than 1 year, back blows and chest thrusts are administered. The Heimlich maneuver can be used in children older than 1 year.

A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child's pulse oximetry status? a. Continuous b. Every 30 minutes c. Every hour d. Every 2 hours

A The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring.

A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF). Which is/are the earliest recognizable clinical manifestation(s) of CF? a. Meconium ileus b. History of poor intestinal absorption c. Foul-smelling, frothy, greasy stools d. Recurrent pneumonia and lung infections

A The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF.

Assist the patient to the bathroom every 2 hours during the day.

A 78-year-old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care?

bladder cancer.

A 26-year-old patient who is employed as a hairdresser and has a 10 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for ________________

Give ketorolac (Toradol) 10 mg PO PRN for pain.

A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?

C (The child's age dictates the type and extent of psychologic preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms with the use of visual aids. It is necessary to prepare this age child for procedures. The preschooler is not yet concerned with body image.)

A 3-year-old child with Hirschsprung's disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. Not necessary because of child's age. b. Not necessary because the colostomy is temporary. c. Necessary because it will be an adjustment. d. Necessary because the child must deal with a negative body image.

Importance of genetic counseling

A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?

A, C, D (A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance)

A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the child's parents (Select all that apply)? a. Replace whole milk with 2% or 1% milk b. Increase servings of red meat c. Increase servings of fish d. Avoid excessive intake of fruit juices e. Limit servings of whole grain

C (After the first priority of establishing an airway, epinephrine is the drug of choice. Benadryl is not a strong enough antihistamine for this severe a reaction. Dopamine and calcium chloride are not appropriate drugs for this type of reaction. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1358 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration? a. Diphenhydramine (Benadryl) b. Dopamine c. Epinephrine d. Calcium chloride

A (Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Infection is not a clinical consequence of cyanosis. Although dehydration can occur in cyanotic heart disease, it is not a compensatory mechanism for chronic hypoxia. It is not a clinical consequence of cyanosis. Anemia may develop as a result of increased blood viscosity. Anemia is not a clinical consequence of cyanosis. PTS: 1 DIF: Cognitive Level: Analysis REF: 1337 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia b. Infection c. Dehydration d. Anemia

Large container for urine

A creatinine clearance test is ordered for a hospitalized patient with possible renal insufficiency. Which equipment will the nurse need to obtain?

A (Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medications are not recommended in infants and small children.)

A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse's response should be based on knowledge that this drug is: a. Not indicated. b. Indicated because it slows intestinal motility. c. Indicated because it decreases diarrhea. d. Indicated because it decreases fluid and electrolyte losses.

B, D (The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.)

A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include (Select all that apply): a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.

blood urea nitrogen (BUN) and creatinine.

A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's _______________

B (For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infant's physical needs but also on the parents' emotional needs. The mother needs to be able to express her feelings before the acceptance of her child can occur. Although discussing plastic surgery will be addressed, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The child's normalcy is emphasized, and the mother is assisted to recognize the child's uniqueness. A focus on abnormal maternal-infant attachment would be inappropriate at this time.)

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be to: a. Restate what the physician has told her about plastic surgery. b. Encourage her to express her feelings. c. Emphasize the normalcy of her baby and the baby's need for mothering. d. Recognize that negative feelings toward the child continue throughout childhood.

C, D, E (The parents should be instructed to notify the physician after their infant's cardiac surgery for a temperature above 37.7° C (100° F); new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly. PTS: 1 DIF: Cognitive Level: Application REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance)

A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what conditions occur (Select all that apply)? a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7° C (100° F) d. New, frequent coughing e. Turning blue or bluer than normal

C (Primary hypertension in children may be treated with weight reduction and exercise programs. If ineffective, pharmacologic intervention may be needed. Primary hypertension is considered an inherited disorder. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1350 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance)

A nurse is teaching an adolescent about primary hypertension. The nurse knows that which of the following is correct? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise.

B (Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the interventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1327 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation)

A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect b. Tetralogy of Fallot c. Ventricular septal defect d. Patent ductus arteriosus

B (Giardia is a parasite that represents 15% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.)

A parasite that causes acute diarrhea is: a. Shigella organisms. b. Giardia lamblia. c. Salmonella organisms. d. Escherichia coli.

infuse a bolus of normal saline.

A patient complains of leg cramps during hemodialysis. The nurse should first _____________

Milk of magnesia 30 mL

A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required?

Apply a pressure dressing and keep the patient on the affected side for 30 to 60 minutes.

A patient with diabetic nephropathy is admitted for a right renal biopsy. Immediately after the biopsy, which of these is an essential nursing action?

potassium.

A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient's ___________________

anticoagulants.

A patient with nephrotic syndrome develops flank pain. The nurse will anticipate teaching the patient about treatment with ______________

A (Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.)

A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with: a. Intravenous fluids. b. Oral rehydration solution (ORS). c. Clear liquids, 1 to 2 ounces at a time. d. Administration of antidiarrheal medication.

An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (Select all that apply.) a. Cluster care to conserve energy b. Round-the-clock administration of antitussive agents c. Strict intake and output to avoid congestive heart failure d. Administration of antibiotics

A, D Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased pulmonary reserve, and the clustering of care is essential. Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential to kept secretions as liquefied as possible.

The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which action should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief. c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. e. Encourage the child to cough frequently.

A, C, D Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should be placed on the abdomen or the side to facilitate drainage. The child can drink diluted juice, cool water, or popsicles after the procedure. An ice collar should be used after surgery. Frequent coughing and nose blowing should be avoided.

When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? A Tofu B Walnuts C Tuna fish D Whole milk E Orange juice

A,B,C Rationale: Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

What is the most common cause of pyelonephritis? A. Escherichia coli B. Staphylococci C. Streptococci D. Klebsiella

A. Escherichia coli Pyelonephritis usually begins with colonization and infection of the lower urinary tract by the ascending urethral route. Bacteria normally found in the intestinal tract, such as E. coli, Proteus, Klebsiella, and Enterobacter species, frequently cause pyelonephritis; the most common cause is E. coli.

A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. Which teaching point should you emphasize before the procedure? A. "You may have pink-tinged urine and a burning sensation after the cystoscopy." B. "You'll need to refrain from eating or drinking after midnight the day before the test." C. "You'll require a urinary catheter inserted before the cystoscopy, and it will be in place for a few days." D. "The morning of the test, the nurse will ask you to drink some water that contains a contrast solution."

A. "You may have pink-tinged urine and a burning sensation after the cystoscopy." Pink-tinged urine, a burning sensation, and frequency are common after a cystoscopy. The patient does not need to be NPO before the test, and a contrast solution is unnecessary. Cystoscopy does not always necessitate catheterization before or after the procedure.

A child with cystic fibrosis is hospitalized for a respiratory infection. Which documentation in the chart would indicate the need for counseling regarding nutrition and gastrointestinal complications? A. Frothy, foul-smelling stools B. Weight unchanged from yesterday C. Consumption of high sodium foods D. Eats 3 snacks every day

A. Frothy, foul-smelling stools

Which are characteristic clinical manifestations of acute poststreptococal glomerulonephritis (APSGN)? A. Hematuria and dependent edema B. Anterior pelvic pain and glycosuria C. Lower back pain and inflamed kidneys D. Dyspnea and dull, aching pain over the urinary bladder

A. Hematuria and dependent edema Generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria may occur. Fluid retention results from decreased glomerular filtration. The edema appears initially in low-pressure tissues, such as around the eyes (periorbital edema), but it later progresses to involve the total body as ascites or peripheral edema in the legs.

The parents of a child with cystic fibrosis inform the nurse that they will be unable to perform postural drainage at home bc their bed doesn't recline like the hospital bed. The nurses response is based on an understanding that: A. Postural drainage is essentail to mobilize secretions in the airways so they can be coughed out. B. Postural drainage is not necessary as long s the child takes his pulmozyme to decrease the viscosity of the mucus C. Postural drainage doesn't influence the pulmonary status of a child with cystic fibrosis D. The parents can be referred to the cystic fibrosis foundation for a flexible bed

A. Postural drainage is essentail to mobilize secretions in the airways so they can be coughed out.

A child with chronic asthma develops Cushing's syndrome. Development of the complication can most likely be attributed to long-term use of: A. Prednisone B. Theophylline C. Ipratropium (Atrovent) D. Cromolyn sodium

A. Prednisone

What should discharge teaching for the patient with pyelonephritis include (select all that apply)? A. Rest often throughout the day B. Eliminate all juices from the diet C. Drink at least 8 glasses of fluid per day D. Complete the entire antibiotic prescription E. Return to the physician for a follow-up urine culture

A. Rest often throughout the day C. Drink at least 8 glasses of fluid per day D. Complete the entire antibiotic prescription E. Return to the physician for a follow-up urine culture Nursing interventions depend on the severity of symptoms. These interventions include teaching the patient about the disease process, with emphasis on (1) the need to continue drugs as prescribed, (2) the need for a follow-up urine culture to ensure proper management, and (3) identification of risk for recurrence or relapse. In addition to antibiotic therapy, encourage the patient to drink at least eight glasses of fluid every day, even after the infection has been treated. Rest is often indicated to increase patient comfort. There is no need to eliminate juice.

Which urinalysis results most likely indicate glomerular damage? A. Smoky color; 30 mg/dL of protein; pH of 6.2 B. Cloudy, yellow; 50 WBCs/hpf; pH of 8.2; numerous casts C. Cloudy, brown; ammonia odor; specific gravity of 1.030; 3 RBCs/hpf. D. Clear, colorless; trace of glucose; trace of ketones; osmolality of 500 mOsm/kg (500 mmol/kg)

A. Smoky color; 30 mg/dL of protein; pH of 6.2 The clinical manifestations of acute poststreptococcal glomerulonephritis (APSGN) appear as a variety of signs and symptoms, including generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria may occur.

The child in respiratory distress require intubation. The nurse would estimate the endotracheal tube size based own: A. The child's little finger B. Whether the child is mouth or nose breathing C. The height of the child D. Whether the child has nasal flaring or retractions

A. The child's little finger

To help reduce the incidence of acute glomerulonephritis, public health teaching can stress the importance of A. early treatment of strep throat. B. obtaining a yearly screening urinalysis. C. proper urinary hygiene to prevent cystitis. D. early immunizations against streptococcal pneumonia.

A. early treatment of strep throat. One of the most important ways to prevent APSGN is to encourage early diagnosis and treatment of sore throats and skin lesions. If streptococci are found in the culture, treatment with appropriate antibiotic therapy (usually penicillin) is essential. The patient must be encouraged to take the full course of antibiotics to ensure that the bacteria have been eradicated.

Epiglottis (bacterial croup): AIR RAID

A: airway inflammation-> obstruction I: increased pulse R: restlessness R: retractions A: anxiety increased I: inspiratory stridor D: drooling -treatments: decrease the anxiety,don't examine throat, position for comfort, teach tray or endotracheal tube available, cool mist, humidification, oxygen, no oral fluids, IV fluids

What should the nurse include in a teaching plan for the parents of a child with vesicoureteral reflux? a. The importance of taking prophylactic antibiotics b. Suggestions for how to maintain fluid restrictions c. The use of bubble baths as an incentive to increase bath time d. The need for the child to hold urine for 6 to 8 hours

ANS: A A Prophylactic antibiotics are used to prevent urinary infection in a child with vesicoureteral reflux, although this treatment plan has become controversial. B Fluids are not restricted when a child has vesicoureteral reflux. In fact, fluid intake should be increased as a measure to prevent UTIs. C Bubble baths should be avoided to prevent urethral irritation and possible UTI. D To prevent UTIs, the child should be taught to void frequently and never resist the urge to urinate.

2. The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect is: a. a loud, harsh murmur with a systolic tremor. b. cyanosis when crying. c. blood pressure higher in the arms than in the legs. d. a machinery-like murmur.

ANS: A A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect. DIF: Cognitive Level: Analysis REF: pp. 613-614 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. Chronic pancreatitis may lead to a. diabetes mellitus. b. Crohn disease. c. gallstones. d. celiac sprue.

ANS: A About 10% to 15% of patients will present not with pain, but rather with the sequelae of chronic pancreatitis, including diabetes mellitus, malabsorption, and weight loss. Chronic pancreatitis does not lead to Crohn disease. Increased incidence of gallstones is not the result of chronic pancreatitis. Celiac sprue is not related to chronic pancreatitis.

18. Steatohepatitis is caused by an accumulation of ________ in the liver cells. a. fat b. bile c. acetaminophen d. ferritin

ANS: A Alcoholic fatty liver (alcoholic steatohepatitis) is an accumulation of fat in the liver cells. It is caused by more fat being delivered to the hepatocyte than it can normally metabolize or by a defect in fat metabolism within the cell. An accumulation of bile does not contribute to steatohepatitis. Steatohepatitis is not related to an accumulation of acetaminophen levels. Serum ferritin levels are elevated in patients with hereditary hemochromatosis.

10. Celiac sprue is a malabsorptive disorder associated with a. inflammatory reaction to gluten-containing foods. b. megacolon at regions of autonomic denervation. c. ulceration of the distal colon and rectum. d. deficient production of pancreatic enzymes.

ANS: A Celiac disease (also called celiac sprue) is characterized by intolerance of gluten, a protein in wheat and wheat products. Current research suggests that celiac sprue is an immune disorder. The main pathologic finding is villus atrophy, with a decrease in the activity and amount of surface epithelial enzymes. Celiac sprue is not associated with ulceration of the distal colon and rectum. Celiac disease is an intolerance of gluten.

12. Untreated acute cholecystitis may lead to ________ of the gallbladder wall. a. gangrene b. infection c. distention d. inflammation

ANS: A If left untreated, the inflammatory process often escalates, and gangrene of the gallbladder wall with rupture may occur. Acute cholecystitis is defined as acute inflammation of the gallbladder wall. Distention of the gallbladder wall is not a risk factor related to untreated cholecystitis. Acute cholecystitis is defined as acute inflammation of the gallbladder wall.

10. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the father understood the instructions when he states "If the baby turns blue, I will: a. hold him against my shoulder with his knees bent up toward his chest." b. lay him down on a firm surface with his head lower than the rest of his body." c. immediately put the baby upright in an infant seat." d. put the baby in supine position with his head elevated."

ANS: A In the event of a paroxysmal hypercyanotic or "tet" spell, the infant should be placed in a knee-chest position. DIF: Cognitive Level: Application REF: p. 616 OBJ: 4 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

9. The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" The nurse's response is based on the understanding that: a. inflammation weakens blood vessels, leading to aneurysm. b. increased lipid levels lead to the development of atherosclerosis. c. untreated disease causes mitral valve stenosis. d. altered blood flow increases cardiac workload with resulting heart failure.

ANS: A Inflammation of vessels weakens the walls of the vessels and often results in aneurysm. DIF: Cognitive Level: Analysis REF: p. 623 OBJ: 11 TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. A patient with chronic gastritis would likely be tested for a. Helicobacter pylori. b. occult blood. c. lymphocytes. d. herpes simplex.

ANS: A It is now known that H. pylori causes chronic, superficial gastritis in virtually all infected persons. Once established in the gastric mucosa, H. pylori sets up a destructive pattern of persistent inflammation. The presence of bloody stools is not generally seen in chronic gastritis. Lymphocytes are not tested in the presence of chronic gastritis. Herpes simplex is not a manifestation of chronic gastritis.

22. Premature infants are at greater risk for developing a. necrotizing enterocolitis. b. pseudomembranous colitis. c. appendicitis. d. diverticular disease.

ANS: A Necrotizing enterocolitis (NEC) is a disorder occurring most often in premature infants (less than 34 weeks' gestation) and infants with low birth weight (less than 5 lbs. or 2.25 kg). This disorder is characterized by diffuse or patchy intestinal necrosis accompanied by sepsis. Pseudomembranous colitis is an acute inflammation and necrosis of the large intestine caused by Clostridium difficile, usually affecting the mucosa but sometimes extending to other layers. The most common cause of emergency surgery on the abdomen, appendicitis is an inflammation of the vermiform appendix. The prevalence of diverticular disease increases with age.

1. Normal bile is composed of a. water, electrolytes, and organic solutes. b. proteins. c. bile acids. d. phospholipids.

ANS: A Normal bile is composed primarily of water, electrolytes, and organic solutes. Bile has a low protein content. The low amount of protein in bile contains bile acids, pigment, cholesterol, and phospholipids. Phospholipids are part of the low protein content in bile.

1. The nurse explains that a ventricular septal defect will allow: a. blood to shunt left to right, causing increased pulmonary flow and no cyanosis. b. blood to shunt right to left, causing decreased pulmonary flow and cyanosis. c. no shunting because of high pressure in the left ventricle. d. increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume.

ANS: A Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis. DIF: Cognitive Level: Analysis REF: p. 613 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A patient being treated for hepatic encephalopathy could be expected to receive a(n) ________diet. a. low-protein and high-fiber b. high-protein and high-carbohydrate c. high-sodium d. unrestricted

ANS: A Restriction of protein is indicated for chronic encephalopathy, along with enhanced elimination of toxic nitrogenous substances. High fiber intake may help decrease constipation. As ammonia levels drop, protein is reintroduced into the diet. When protein is restricted, carbohydrate levels should be at least 400 g. Excessive levels of sodium in the diet are contraindicated with renal insufficiency. Dietary restrictions are utilized in patients with hepatic encephalopathy.

5. Acute right lower quadrant pain associated with rebound tenderness and systemic signs of inflammation are indicative of a. appendicitis. b. peritonitis. c. cholecystitis. d. gastritis.

ANS: A The earliest manifestation of appendicitis is generalized periumbilical pain accompanied by nausea and, occasionally, diarrhea. The pain is often described as "migrating" or localizing to the lower right abdomen (McBurney's point) due to distention of the serosa from inflammatory edema, at which time fever usually manifests. Acute localized pain with rebound tenderness is not associated with peritonitis. Cholecystitis is not manifested by lower quadrant pain. Gastritis is not associated with symptoms of right lower quadrant pain and systemic inflammation.

11. The most common causes of prehepatic jaundice are ________ and ineffective erythropoiesis. a. hemolysis b. metabolism c. fibrosis d. canalicular bilirubin transport

ANS: A The most common causes of prehepatic jaundice are hemolysis and ineffective erythropoiesis. The reabsorption of large hematomas in patients with mild liver disease is a frequent and harmless cause of mild jaundice. Dysfunction of each of the hepatic steps in bilirubin metabolism may cause jaundice. Increased resistance from fibrosis may cause jaundice in the cholestatic pathway. At the canalicular posthepatocytic level, jaundice may occur due to conjugated hyperbilirubinemia.

4. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting: a. increases the return of venous blood back to the heart. b. decreases arterial blood flow away from the heart. c. is a common resting position when a child is tachycardic. d. increases the workload of the heart.

ANS: A The squatting position allows the child to breathe more easily because systemic venous return is increased. DIF: Cognitive Level: Analysis REF: p. 616 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. Ulcerative colitis is commonly associated with a. bloody diarrhea. b. malabsorption of nutrients. c. fistula formation between loops of bowel. d. inflammation and scarring of the submucosal layer of the bowel.

ANS: A Ulcerative colitis (inflammation and ulceration of the colon and rectal mucosa) is manifested as bloody diarrhea and abdominal pain. Ulcerative colitis is not associated with malabsorption of nutrients. Fistula formation in the bowel is related to Crohn disease. Acute inflammation of the intestinal wall may manifest as pseudomembranous enterocolitis or necrotizing enterocolitis.

5. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because blood is: a. circulated through the lungs again, causing pulmonary circulatory congestion. b. shunted past the pulmonary circulation, causing pulmonary hypoxia. c. shunted past cardiac arteries, causing myocardial hypoxia. d. circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.

ANS: A When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation. DIF: Cognitive Level: Analysis REF: p. 614 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. Chronic cholecystitis can lead to (Select all that apply.) a. biliary sepsis. b. calcified gallbladder. c. porcelain gallbladder. d. cirrhosis. e. diabetes mellitus.

ANS: A, B, C Chronic cholecystitis may lead to biliary sepsis, as well as a specific type of scarring known as a calcified or porcelain gallbladder. Chronic cholecystitis is associated with a higher risk of cancer, not cirrhosis which affects the liver. Diabetes mellitus is a predisposing factor of chronic cholecystitis. Chronic cholecystitis does not cause diabetes mellitus.

24. A disorder of the esophageal smooth muscle function where dysphagia is a symptom is (Select all that apply.) a. esophageal stricture. b. achalasia. c. esophageal tumors. d. Mallory-Weiss syndrome. e. hiatal hernia.

ANS: A, B, C Esophageal stricture, achalasia, and esophageal tumors are all disorders of the esophageal smooth muscle function that cause dysphagia. Manifestations of Mallory-Weiss syndrome include vomiting of blood and passing of large amounts of blood rectally after an episode of forceful vomiting. Hiatal hernia is a defect of the diaphragm, not the esophagus, even though hiatal hernia is associated with dysphagia.

21. What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? Select all that apply. a. Spontaneous cyanosis b. Dyspnea c. Weakness d. Dry cough e. Syncope

ANS: A, B, C, E Indicators of a paroxysmal hypercyanotic episode or a "tet" episode are spontaneous cyanosis, dyspnea, weakness, and syncope. DIF: Cognitive Level: Comprehension REF: pp. 615-616 OBJ: 3 TOP: "Tet" Spells KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue? Select all that apply. a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula

ANS: A, B, C, E Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held. DIF: Cognitive Level: Comprehension REF: p. 618 OBJ: 5 TOP: Feeding Infant with CHF KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

25. Crohn disease is associated with what complications? (Select all that apply.) a. Perianal fissures b. Fistulae c. Green stool d. Abscesses e. Rectal pain

ANS: A, B, D Complications such as perianal fissures, fistulae, and abscesses are common in Crohn disease and may be the symptoms that lead individuals to seek health care. The stool may be bloody, and thus would be red or black, not green. In Crohn disease, abdominal pain is often constant and in the right lower quadrant of the abdomen.

17. Patients who may be at risk for development of cholesterol gallstones include (Select all that apply.) a. high spinal cord injuries. b. patients receiving total parenteral nutrition. c. patients receiving chemotherapy. d. patients with rapid weight loss. e. pregnant women.

ANS: A, B, D, E A significant factor that promotes the continued growth of stones is hypomotility or stasis of bile within the gallbladder. Patients with high spinal cord injuries, patients receiving total parenteral nutrition, and persons who undergo prolonged fasting or rapid weight loss have impaired emptying and are at particular risk for development of cholesterol gallstones. Other risk factors for cholelithiasis include pregnancy, oral contraceptives, obesity, and diabetes mellitus. Patients receiving chemotherapy are not at greater risk for developing gallstones.

20. The nurse uses a diagram to illustrate what four structural heart anomalies that comprise tetralogy of Fallot? Select the four that apply. a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventral septal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta

ANS: A, B, D, E The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus, stenosis of pulmonary artery, and dextroposition of the aorta. DIF: Cognitive Level: Comprehension REF: p. 615 OBJ: 4 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

26. What is a pathophysiologic mechanism involved in the development of diarrhea? (Select all that apply.) a. Osmotic diarrhea b. Excessive flatus c. Secretory diarrhea d. Exudative diarrhea e. Motility disturbances

ANS: A, C, D, E Osmotic diarrhea is due to increased amounts of poorly absorbed solutes in the intestine. Secretory diarrhea is usually due to toxins that stimulate intestinal fluid secretion and impair absorption. Exudative diarrhea (mucus, blood, protein) results from inflammatory processes. A decreased transit time in the small intestine results in diarrhea because the absorptive capacity of the large intestine is exceeded. Excessive gas in the intestine is not a mechanism for developing diarrhea.

A nurse is assessing an infant for urinary tract infection (UTI). Which assessment findings should the nurse expect? Select all that apply. a. Change in urine odor or color b. Enuresis c. Fever or hypothermia d. Voiding urgency e. Poor weight gain

ANS: A, C, E Correct The signs of a UTI in an infant include fever or hypothermia, irritability, dysuria as evidenced by crying when voiding, change in urine odor or color, poor weight gain, and feeding difficulties. Incorrect Enuresis and voiding urgency should be assessed in an older child.

22. The nurse explains that which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? Select all that apply. a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Dextroposition of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs)

ANS: A, D, E The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus. DIF: Cognitive Level: Comprehension REF: p. 612 OBJ: 3 TOP: Congenital Heart Defects KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

1. Which symptom suggests the presence of a hiatal hernia? a. Nausea b. Heartburn c. Diarrhea d. Abdominal cramps

ANS: B Individuals with hiatal hernia are predisposed to GERD and may experience symptoms such as heartburn, chest pain, and dysphagia. Nausea and abdominal cramps are not symptoms that suggest hiatal hernia. Hiatal hernia is not manifested by diarrhea.

6. Liver transaminase elevations in which aspartate aminotransferase (AST) is markedly greater than alanine aminotransferase (ALT) is characteristic of a. viral hepatitis. b. alcohol-induced injury. c. cirrhosis. d. acetaminophen toxicity.

ANS: B Alcoholic and other toxic hepatitides virtually always show the aspartate aminotransferase (AST) markedly elevated in comparison with the alanine aminotransferase (ALT). In viral hepatitis, the alanine aminotransferase (ALT) is markedly higher than the aspartate aminotransferase (AST). Jaundice in patients with cirrhosis often shows elevations in all parameters, reflecting the widespread liver dysfunction and obstruction of the bile canals and small vessels due to scarring. Acetaminophen toxicity will cause signs of hepatic injury within 24 to 48 hours, including abnormal liver enzyme levels.

6. An appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant would be: a. counting the apical rate for 30 seconds before administering the medication. b. withholding a dose if the apical heart rate is less than 100 beats/min. c. repeating a dose if the child vomits within 30 minutes of the previous dose. d. checking respiratory rate and blood pressure before each dose.

ANS: B As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified. DIF: Cognitive Level: Application REF: p. 618 OBJ: 5 TOP: Congestive Heart Failure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

16. Hepatitis with the presence of autoantibodies and positive antinuclear antibodies (ANA) is a. hepatitis D. b. autoimmune hepatitis. c. hepatitis A. d. hepatitis B.

ANS: B Autoimmune hepatitis is characterized by the presence of several autoantibodies as well as a polyclonal hypergammaglobulinemia. Antinuclear antibody (ANA) is generally positive at a high level. The diagnosis of hepatitis D is by anti-HDV IgM and IgG enzyme-linked immunosorbent assays. HAV infection is diagnosed through serologic testing. Presence of anti-HAV immune globulin G (IgG) indicates previous infection, and presence of immune globulin M (IgM) indicates acute infection. The serologic diagnosis for hepatitis B is complicated.

12. Barrett esophagus is a a. gastrin secreting lesion. b. preneoplastic lesion. c. benign condition. d. gastrin-secreting tumor.

ANS: B Barrett esophagus is a complication of chronic GERD and represents columnar tissue replacing the normal squamous epithelium of the distal esophagus. It carries a significant risk for esophageal cancer. Patients with Barrett esophagus should undergo regular endoscopic screening for cancer, along with pharmacologic control of their reflux. Barrett esophagus carries a significant risk for esophageal cancer and does not secrete gastrin.

2. Patients with acute pancreatitis are generally made NPO and may require continuous gastric suctioning in order to a. prevent abdominal distention. b. remove the usual stimuli for pancreatic secretion. c. prevent hyperglycemia associated with loss of insulin secretion. d. prevent mechanical obstruction of the intestine.

ANS: B Conservative management is indicated for mild to moderate cases of acute pancreatitis. In general, withholding oral feedings, providing nasogastric suction, and providing careful volume replacement with IV fluids are indicated. Gastric suctioning is not indicated for preventing abdominal distention. Hyperglycemia is not influenced by the presence of gastric suctioning. Continuous gastric suctioning may be used in the presence of a significant ileus.

14. Fecal leukocyte screening would be indicated in a patient with suspected a. lactose intolerance. b. enterocolitis. c. laxative abuse. d. giardiasis.

ANS: B Enterocolitis is manifested by diarrhea (often bloody), abdominal pain, fever, leukocytosis, and rarely, colonic perforation. Lactose intolerance would not be a cause of leukocytosis. Leukocyte screening would not be a factor in laxative use or abuse. Suspected giardiasis would not be a reason to screen fecal leukocytes.

8. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. "He is always hungry." b. "He tires out during feedings." c. "He is fussy for several hours every day." d. "He sleeps all the time."

ANS: B Fatigue during feeding or activity is common to most infants with congenital cardiac problems. DIF: Cognitive Level: Analysis REF: p. 611 OBJ: 3 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. It is true that gallstones are a. a minimal risk for Native Americans. b. more common in women. c. more common in men. d. at highest risk among Asians.

ANS: B Gallstones are twice as common in women as in men. Native Americans, particularly the Pima Indians of North America, are markedly susceptible to gallstones. Gallstones are twice as common in women than men. European Caucasians are intermediate in prevalence, and persons of Asian descent are at the lowest risk.

9. A patient who should be routinely evaluated for peptic ulcer disease is one who is a. taking 6 to 8 tablets of acetaminophen per day. b. being treated with high-dose oral glucocorticoids. c. experiencing chronic diarrhea. d. routinely drinking alcoholic beverages.

ANS: B Glucocorticoids released in response to stress may have a role in the promotion of excess acid production or the destruction of gastric mucosal defenses. Therefore, a patient taking high-dose glucocorticoids would be at higher risk of developing peptic ulcer disease. Acetaminophen is not a risk factor for development of peptic ulcer disease. Chronic diarrhea is not a symptom of peptic ulcer disease. There is little evidence of a pathogenic role for alcohol, spicy foods, and caffeine in the development of peptic ulcer disease.

9. What form of viral hepatitis is likely to be transmitted sexually? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis E

ANS: B Hepatitis B is spread by parenteral contact with infected blood or blood products, including contaminated needles, and by sexual contact. Hepatitis A virus (HAV) is usually spread by the fecal-oral route. The mode of transmission of hepatitis C closely resembles that of HBV, although sexual and perinatal transmission is much less likely. The majority of infections were acquired through IV drug abuse. Hepatitis E is an RNA virus spread via the fecal-oral route, especially through contaminated water.

10. The finding of hypotension, rigid abdomen, and absent bowel sounds in a patient with pancreatitis a. is an expected finding and requires no specific intervention. b. indicates peritonitis with substantial risk for sepsis and shock. c. requires immediate surgical intervention. d. is an unusual finding in pancreatitis and indicates misdiagnosis.

ANS: B In acute pancreatitis, fever is common but is usually low-grade initially. In more severe pancreatitis, hypotension, rigid abdomen, and absent bowel sounds are present. Hypotension, rigid abdomen and absent bowel sounds are unexpected findings. Pancreatic surgery is technically challenging and risky, and generally is only considered as a last resort. Findings indicative of peritonitis do occur and should be treated promptly.

13. A patient admitted with bleeding related to esophageal varices could be expected to receive a continuous intravenous infusion of a. glucose. b. octreotide acetate. c. anticoagulants. d. proton pump inhibitors.

ANS: B Pharmacologic management is used to lower portal pressure by dilating collateral pathways and reducing splanchnic blood flow. Controlling bleeding is often accomplished using vasopressin, but side effects limit its use. Recently, octreotide acetate, a synthetic analog of the naturally occurring hormone somatostatin, has been effectively used as a replacement for vasopressin. Fluid resuscitation is carried out using normal saline. Anticoagulants are contraindicated in a patient with active bleeding. Intravenous proton pump inhibitors may be used, but not as a continuous infusion.

8. What laboratory data would support a diagnosis of hemochromatosis? a. Deficient protease inhibitor b. Elevated ferritin c. Elevated urine copper d. Positive antinuclear antibody

ANS: B Serum iron and ferritin studies are performed to diagnose hemochromatosis. Protease inhibitor is not used to diagnose hemochromatosis. Copper in the urine is not indicative of hemochromatosis. Antinuclear antibody is not diagnostic of hemochromatosis.

18. A patient receiving chemotherapy may be at greater risk for development of a. gastroesophageal reflux. b. stomatitis. c. esophageal varices. d. Mallory-Weiss syndrome.

ANS: B Stomatitis is defined as an ulcerative inflammation of the oral mucosa that may extend to the buccal mucosa, lips, and palate. Among its many causes are pathogenic organisms, including bacteria and viruses; mechanical trauma; exposure to such irritants as alcohol, tobacco, and other chemical substances; certain medications, particularly chemotherapeutic agents. Gastroesophageal reflux disease is not related to chemotherapy. Patients taking chemotherapy are not at greater risk for developing esophageal varices. Chemotherapy is not a risk factor for Mallory-Weiss syndrome.

3. Most gallstones are composed of a. bile. b. cholesterol. c. calcium. d. uric acid salts.

ANS: B The majority of gallstones among patients are cholesterol stones. Cholesterol eventually precipitates from supersaturated bile. Most gallstones are not composed of calcium. Uric acid salts are not the primary composition of gallstones.

16. The pain associated with chronic pancreatitis is generally described as ________ in nature. a. sharp and constant b. steady and boring c. intermittent and burning d. intermittent and stabbing

ANS: B The pain is often accompanied by nausea and is steady and boring in nature. The pain is usually located in the upper abdomen, particularly in the epigastrium, and radiates to the back in more than half of cases. Pain associated with pancreatitis is most often steady in nature. The pain of chronic pancreatitis is often the major form of debility. Nerve fibers from the pancreas pass to the celiac plexus and then to spinal sympathetic ganglia.

12. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints and carditis c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate

ANS: B The presence of two major Jones' criteria would indicate a high probability of rheumatic fever. DIF: Cognitive Level: Analysis REF: p. 621, Box 26-1 OBJ: 6 TOP: Rheumatic Fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are the: a. coronary arteries. b. heart muscle and the mitral valve. c. aortic and pulmonic valves. d. contractility of the ventricles.

ANS: B The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved. DIF: Cognitive Level: Knowledge REF: p. 620 OBJ: 6 TOP: Rheumatic Fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. ________ disease is a rare autosomal recessive disorder in which excessive amounts of copper accumulate in the liver. a. Kayser-Fleischer b. Wilson c. Reye d. Byler

ANS: B Wilson disease, or hepatolenticular degeneration, is a rare autosomal recessive disorder in which excessive amounts of copper accumulate in the liver and other organs. As with hereditary hemochromatosis, it has now been linked to a specific abnormal protein, ATP7B, which results in retention of copper in the liver. Clinical signs and symptoms of Wilson disease include the presence of Kayser-Fleischer rings on the cornea. Reye syndrome is characterized by fatty infiltration of the liver with severe hepatic dysfunction, including encephalopathy, coagulopathy, and elevated levels of hepatocellular enzymes. Byler syndrome, is caused by a single-gene mutation and traces back to an Amish kindred.

A nurse is planning care for a child admitted with nephrotic syndrome. Which interventions should be included in the plan of care? Select all that apply. a. Administration of antihypertensive medications b. Daily weights c. Salt-restricted diet d. Frequent position changes e. Teaching parents to expect tea-colored urine

ANS: B, C, D A. Nephrotic syndrome does not require antihypertensive medications. These are administered for acute glomerulonephritis. B. A child with nephrotic syndrome will need to be monitored closely for fluid excess so daily weights are important. C. The diet is salt restricted to prevent further retention of fluid. D. Because of the fluid excess, frequent position changes are required to prevent skin breakdown. E. Tea-colored urine is expected with acute glomerulonephritis, but not nephrotic Syndrome. The urine in nephrotic syndrome is frothy indicating protein is being lost in the urine.

bladder cancer.

After obtaining the health history for a 25-year-old who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for __________

19. Which digestive enzyme is secreted from the intestinal mucosa during a meal? (Select all that apply.) a. Amylase b. Cholecystokinin c. Trypsinogen d. Lecithin e. Lipase f. Secretin

ANS: B, F The release of digestive enzymes during a meal is controlled by hormones secreted from the small intestinal mucosa: cholecystokinin (CCK) and secretin. The juices themselves are composed of both active digestive enzymes (e.g., amylase, lipase) and precursor or proenzymes (e.g., trypsinogen). Trypsinogen is a proenzyme. Lecithin is unrelated to hormone release during meals.

Parents ask the nurse "when should our child's hypospadias be corrected?" The nurse responds based upon the knowledge that correction of hypospadias should be accomplished by the time the child is a. 1 month of age b. 6 to 12 months of age c. School age d. Sexually mature

ANS: B. 6 to 12 months of age A. Surgery to correct hypospadias is not performed when the infant is this young. B. The correction of hypospadias should ideally be accomplished by the time the child is 6 to 12 months of age and before toilet training. C. It is preferable for hypospadias to be surgically corrected before the child enters school so that the child has normal toileting behaviors in the presence of his peers. D. Corrective surgery for hypospadias is done long before sexual maturity.

"I should start taking a high potency multiple vitamin every morning."

After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient says, __________________

"I will clean the catheter carefully before and after each catheterization."

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective?

Report the patient's symptoms to the health care provider.

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?

15. When the child with rheumatic fever begins involuntary, purposeless movements of her limbs, the nurse recognizes that this is an indication of: a. seizure activity. b. hypoxia. c. Sydenham's chorea. d. decreasing level of consciousness.

ANS: C As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham's chorea manifested by involuntary, purposeless movements of the limbs. DIF: Cognitive Level: Application REF: p. 620 OBJ: 6 TOP: Sydenham's Chorea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A patient with pancreatitis may experience muscle cramps secondary to a. alkalosis. b. hyperglycemia. c. hypocalcemia. d. hypermagnesemia.

ANS: C Associated laboratory findings of acute pancreatitis include leukocytosis, hyperlipidemia, and hypocalcemia. Alkalosis is not associated with pancreatitis. Hyperglycemia would not be a cause for muscle cramps. Hypermagnesemia is not generally related to pancreatitis.

16. The nurse clarifies to the parents of a 4-year-old child recovering from rheumatic fever that the child will need to receive monthly injections of penicillin G for a minimum of _____ year(s). a. 1 b. 2 c. 5 d. 10

ANS: C Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections (about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 to prevent further bouts of rheumatic fever. DIF: Cognitive Level: Comprehension REF: p. 620 OBJ: 7 TOP: Prophylaxis for Rheumatic Fever KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

19. Esophageal varices represent a complication of ________ hypertension. a. primary b. pregnancy-induced c. portal d. secondary

ANS: C Esophageal varices represent a complication of portal hypertension, which in Western society is generally the result of cirrhosis due to alcoholism or viral hepatitis. Primary hypertension is not manifested by esophageal varices. Pregnancy-induced hypertension is unrelated to esophageal varices. Esophageal varices is not a complication of secondary hypertension.

16. An urgent surgical consult is indicated for the patient with acute abdominal pain and a. vomiting. b. CVA tenderness. c. absent bowel sounds. d. borborygmi.

ANS: C Functional bowel obstructions are characterized by the absence of bowel sounds. Uncorrected obstruction may lead to intestinal wall edema, ischemia, and necrosis. Vomiting with abdominal pain is not a cause for urgent surgical consult. CVA tenderness in the presence of abdominal pain is not an indicator for urgent surgical consult. Acute abdominal pain with hyperactive bowel sounds does not indicate the need for an urgent surgical consultation.

17. The nurse is aware that the characteristics of high-density lipoproteins (HDLs) are that they: a. have high amounts of triglycerides. b. have only small amounts of protein. c. have little cholesterol. d. aid in steroid production.

ANS: C HDLs have low amounts of triglycerides, large amounts of proteins, low amount of cholesterol, and are excreted via the liver. They have no role in the production of steroids. DIF: Cognitive Level: Comprehension REF: p. 622 OBJ: 12 TOP: High-Density Lipoproteins KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. Hepatitis B is usually transmitted by exposure to a. hepatitis vaccine. b. feces. c. blood or semen. d. contaminated food.

ANS: C Hepatitis B virus is highly prevalent worldwide. It is spread by parenteral contact with infected blood or blood products, including contaminated needles. HBV vaccine is a recombinant vaccine that is highly immunogenic. After the full course, the antibody response rate is 95% for normal hosts. Hepatitis A is spread by the fecal-oral route. Hepatitis E is spread through contaminated water.

1. Jaundice is a common manifestation of a. malabsorption syndromes. b. anemia. c. liver disease. d. cholecystitis.

ANS: C Jaundice results from impaired bilirubin metabolism and is one of the most characteristic signs of liver disease. Malabsorption syndromes are not manifested by jaundice. Anemia is not manifested by jaundice. Jaundice is not a common manifestation of cholecystitis.

10. Brain injury secondary to high serum bilirubin is called a. hepatic encephalopathy. b. hepatic meningitis. c. kernicterus. d. encephalitis.

ANS: C Kernicterus refers to brain injury as a result of hyperbilirubinemia. It is a serious complication of the neonatal period, generally occurring in the setting of premature birth, neonatal jaundice, and especially hemolytic disease of the newborn. Hepatic encephalopathy is typically characterized by high ammonia levels in the blood. Meningitis is not associated with high serum bilirubin levels. Encephalitis may accompany viral hepatitis in children, but is not related to high serum bilirubin levels.

3. Epigastric pain that is relieved by food is suggestive of a. pancreatitis. b. cardiac angina. c. gastric ulcer. d. dysphagia.

ANS: C Manifestations of peptic ulcer disease include epigastric burning pain that is usually relieved by the intake of food (especially dairy products) or antacids. Pancreatitis is not manifested by epigastric pain. Epigastric pain is not a symptom of cardiac angina. Dysphagia is not associated with epigastric pain relieved by food.

4. Elevated serum lipase and amylase levels are indicative of a. gallbladder disease. b. appendicitis. c. pancreatitis. d. peritonitis.

ANS: C The laboratory evaluation of acute pancreatitis begins with measurements of serum pancreatic enzymes. Serum lipase and amylase levels rise more or less in tandem. Elevated serum lipase and amylase levels are not indicative of gallbladder disease. Appendicitis is not related to lipase and amylase levels. Peritonitis is not caused by elevated serum lipase or amylase levels.

8. An early indicator of colon cancer is a. rectal pain. b. bloody diarrhea. c. a change in bowel habits. d. jaundice.

ANS: C The manifestations of colon cancer depend on the anatomic location and function of the bowel segment containing the tumor. Early manifestations may include a change in bowel habits. Later in the progression of tumor growth, a sensation of rectal fullness and a dull ache may be felt in the rectum or sacral region. Although no signs of obstruction are present, black, tarry stools, which signify bleeding into the intestinal lumen, are a significant finding. Jaundice is not an early indicator of colon cancer.

4. The most common cause of mechanical bowel obstruction is a. volvulus. b. intussusception. c. adhesions. d. fecal impaction.

ANS: C The most frequent contributing factors for bowel obstructions are previous abdominal surgery with adhesions and congenital abnormalities of the bowel. Intestinal obstruction can be caused by volvulus. Intussusception can be related to bowel obstruction, but the most common cause is surgical adhesions. Mechanical bowel obstructions can be related to fecal impaction, but this is not the most common cause.

11. What clinical finding would suggest an esophageal cause of a client's report of dysphagia? a. Nasal regurgitation b. Airway obstruction with swallowing c. Chest pain during meals d. Coughing when swallowing

ANS: C Two types of pain occur in the esophagus: (1) heartburn (also called pyrosis) and (2) pain located in the middle of the chest, which may mimic the pain of angina pectoris. Heartburn is caused by the reflux of gastric contents into the esophagus and is a substernal burning sensation that may radiate to the neck or throat. A person experiencing pharyngeal contractions may cough and expel the ingested food or fluids through their mouth and nose or aspirate when they attempt to swallow. Airway obstruction with swallowing would be an oropharyngeal cause of dysphagia. A person experiencing pharyngeal contractions may cough and expel the ingested food or fluids through his or her mouth and nose or aspirate when he or she attempts to swallow.

14. More than half of the initial cases of pancreatitis are associated with a. trauma. b. stones. c. alcoholism. d. high cholesterol.

ANS: C Up to 66% of first cases of pancreatitis are associated with alcoholism. Trauma is a possible mechanism for acinar cell injury. A prominent factor in pancreatitis is obstruction of the pancreatic duct by a stone. Hypertriglyceridemia is a predisposing factor for pancreatitis in the United States.

The nurse assessing a child with acute poststreptococcal glomerulonephritis should be alert for which finding? a. Increased urine output b. Hypotension c. Tea-colored urine d. Weight gain

ANS: C. Tea-colored urine A In acute poststreptococcal Glomerulonephritis the urine output may be decreased. B In acute poststreptococcal glomerulonephritis blood pressure may be increased. C Acute poststreptococcal glomerulonephritis is characterized by hematuria, proteinuria, edema, and renal insufficiency. Tea-colored urine is an indication of hematuria. D Edema may be noted around the eyelids and ankles in patients with acute poststreptococcal glomerulonephritis; however, weight gain is associated with nephrotic syndrome.

23. Dumping syndrome is commonly seen after __________ procedures. a. appendectomy b. intestinal biopsy c. colonoscopy d. gastric bypass

ANS: D Dumping syndrome is a term used to describe the literal dumping of stomach contents into the proximal portion of the small intestine because of impaired gastric emptying. Interestingly, dumping seems to occur only with Roux-en-Y gastric bypass procedures. Dumping syndrome is not related to procedures involving appendectomy. Intestinal biopsies do not produce a dumping effect. Colonoscopies are not related to dumping syndrome.

The mother has been taught to perform chest PT on her child. Which observation by the nurse indicates the need for additional teaching A. The child has on only a T-shirt. B. The mother delayed the treatment until the child had finished breakfast. C. The mother is making a popping sound when doing percussion D. The child is positioned in various head-down positions

B. The mother delayed the treatment until the child had finished breakfast.

18. The school nurse recommends a heart healthy diet that limits fats to no more than ____% of the total dietary intake. a. 10 b. 15 c. 20 d. 30

ANS: D DIF: Cognitive Level: Knowledge REF: p. 622 OBJ: 12 TOP: Heart Healthy Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

14. The nurse is aware that the infant born with hypoplastic left heart syndrome must acquire his or her oxygenated blood through: a. the patent ductus arteriosus. b. a ventricular septal defect. c. the closure of the foramen ovale. d. an atrial septal defect.

ANS: D Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs. DIF: Cognitive Level: Application REF: p. 616 OBJ: 3 TOP: Hypoplastic Left Heart Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. It is true that biliary cancer a. is most often cured by surgery. b. respond well to chemotherapy. c. are identifiable and treatable when diagnosed early. d. tend to be asymptomatic and progress insidiously.

ANS: D Biliary cancers tend to be asymptomatic and progress insidiously until well advanced. Surgery for cure is a treatment option in fewer than 10% of cases. Chemotherapy and radiation therapy are indicted for palliation, and certain patients may benefit from stenting and other procedures to alleviate biliary obstruction. Cancers of the biliary system are relatively rare, accounting for only 1 to 2 cases per 100,000 per year. Unfortunately, they tend to be asymptomatic and progress insidiously until well advanced.

15. What finding would rule out a diagnosis of irritable bowel syndrome in a patient with chronic diarrhea? a. Negative stool leukocytes b. Intermittent constipation c. Abdominal pain and distention d. Bloody stools

ANS: D Bloody stools are not a symptom of irritable bowel syndrome. A person with irritable bowel syndrome would have negative stool leukocytes. The manifestations of IBS may vary greatly, with some persons experiencing only diarrhea or constipation and others experiencing an alternating pattern of both. In addition to cramping abdominal pain, manifestations such as nausea and mucus in the stool may also be present.

13. What finding should prompt further diagnostic testing in a child presenting with diarrhea? a. Periumbilical discomfort b. Greenish, watery diarrhea c. Frequent, large-volume diarrhea d. Blood and mucus in the stools

ANS: D Both ulcerative colitis and Crohn disease have their onset most commonly in childhood and young adulthood, with obviously profound implications. Stools may contain blood or mucus. Periumbilical discomfort, watery diarrhea, and frequent, large volume diarrhea are not causes for further diagnostic testing.

15. An infusion of mannitol would be prescribed to treat a. varices. b. encephalopathy. c. peritonitis. d. cerebral edema.

ANS: D Cerebral edema is managed primarily by the intravenous infusion of mannitol, which by increasing serum osmolarity draws water from the brain and thus reduces the swelling. Octreotide acetate is used in the management of varices. Hepatic encephalopathy would be treated with lactulose. Peritonitis is managed with the use of antimicrobial agents.

11. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" The nurse bases a response on the understanding that clubbing occurs as a result of: a. untreated congestive heart failure. b. a left-to-right shunting of blood. c. decreased cardiac output. d. chronic hypoxia.

ANS: D Clubbing of the fingers develops in response to chronic hypoxia. DIF: Cognitive Level: Analysis REF: p. 617 OBJ: 4 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A patient with a history of alcoholism presents with hematemesis and profound anemia. The expected diagnosis is a. ascites. b. cerebral edema. c. hepatic encephalopathy. d. gastroesophageal varices.

ANS: D Esophageal varices primarily results from portal hypertension due to chronic alcoholism or hepatitis. Initial symptoms are bleeding, anemia, and shock. Ascites is an accumulation of fluid in the abdominal cavity. Cerebral edema is swelling of the brain related to hepatic encephalopathy. Hepatic encephalopathy does not cause symptoms related to bleeding.

2. Pathophysiologically, esophageal varices can be attributed to a. elevated bilirubin. b. diminished protein metabolism. c. fluid accumulation. d. portal hypertension.

ANS: D Esophageal varices result mainly from portal hypertension, which in Western society is generally the result of cirrhosis due to the chronic effects of alcoholism or viral hepatitis. Elevated bilirubin is not attributed to esophageal varices. Diminished protein metabolism does not contribute to esophageal varices. Increased vascular resistance in the liver plays a prominent role in the formation of variceal esophageal veins.

6. A silent abdomen 3 hours after bowel surgery most likely indicates a. peritonitis. b. mechanical bowel obstruction. c. perforated bowel. d. functional bowel obstruction.

ANS: D Functional obstruction or ileus refers to the loss of propulsive ability by the bowel and may occur after abdominal surgery or in association with hypokalemia, peritonitis, severe trauma, spinal fractures, ureteral distention, and the administration of medications such as narcotics. Peritonitis may be associated with functional obstruction. Mechanical obstructions are due to adhesions, hernia, tumors, impacted feces, volvulus (twisting), or intussusception (telescoping). Perforated bowel is a rare condition sometimes associated with Crohn disease.

4. Hepatic encephalopathy is associated with a. hyperbilirubinemia. b. hyperuricemia. c. toxic effects of alcohol on brain cells. d. increased blood ammonia levels.

ANS: D Hepatic encephalopathy is associated with liver failure or liver disease. It is positively correlated with elevated arterial ammonia levels. Hyperbilirubinemia is not related to hepatic encephalopathy but is associated with hypokalemia, hyponatremia, alkalosis, hypoxia, and hypercarbia. Hyperuricemia is not associated with hepatic encephalopathy. Hepatic encephalopathy is a complex neuropsychiatric syndrome characterized by symptoms ranging from mild confusion and lethargy to stupor and coma.

A (This combination of drug therapy is effective in the treatment and eradication of H. pylori.)

Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to: a. Eradicate Helicobacter pylori. b. Treat epigastric pain. c. Coat gastric mucosa. d. Reduce gastric acid production.

5. An increased urine bilirubin is associated with a. an increased indirect serum bilirubin. b. hemolytic reactions. c. Gilbert syndrome. d. hepatitis.

ANS: D In the presence of liver disease, the hepatic fraction of bilirubin decreases and the urinary fraction increases, thus accounting for a rise in urinary urobilinogen seen with liver dysfunction and hepatitis. An increase in indirect serum bilirubin is a sign of liver disease. Hemolytic reactions do not cause an increase in urine bilirubin. Disorders of the bile acid transport will cause an increase in serum bilirubin.

6. A biliary cause of acute pancreatitis is suggested by an elevation in which serum laboratory results? a. Lipase b. Amylase c. Glucose d. Alkaline phosphatase

ANS: D Marked elevation of the alkaline phosphatase and bilirubin levels suggest the possibility of biliary disease or obstruction, particularly by gallstones. Elevated serum lipase levels and elevated glucose levels do not suggest a biliary cause of pancreatitis. Acute pancreatitis is evidenced by elevated serum amylase and lipase levels, but does not indicate biliary disease.

2. Proton pump inhibitors may be used in the management of peptic ulcer disease to a. increase gastric motility. b. inhibit secretion of pepsinogen. c. neutralize gastric acid. d. decrease hydrochloric acid (HCl) secretion.

ANS: D Proton pump inhibitors are generally given to block acid secretion in individuals with peptic ulcer disease. The major treatment objectives for PUD are to encourage healing of the injured mucosa by reducing gastric acidity and to prevent recurrence. Proton pump inhibitors are not used to inhibit secretion of pepsinogen. Gastric acid is not neutralized by the use of proton pump inhibitors.

21. Rupture of esophageal varices is a complication of cirrhosis with portal hypertension and carries a high ________ rate. a. cure b. morbidity c. insurance d. mortality

ANS: D Rupture of esophageal varices is a dreaded complication of cirrhosis with portal hypertension and carries a high mortality rate. Rupture of esophageal varices does not carry a high cure rate. Varices will affect more than half of cirrhotic patients, and approximately 30% of them experience an episode of variceal hemorrhage within 2 years of the diagnosis of varices. Insurance is not a factor in the rupture of esophageal varices.

5. The definitive treatment for cholecystitis is a. lithotripsy of stones. b. chemical dissolution of stones. c. antibiotics and anti-inflammatories. d. cholecystectomy.

ANS: D Surgical removal of the gallbladder is the definitive treatment for cholecystitis. Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstones. Extracorporeal shock wave lithotripsy (ESWL), which involves the breaking up of gallstones using shock waves, is a nonsurgical approach which could lead to recurrence of stones. Chemodissolution of stones has a low overall efficacy. Antibiotics are generally used with acute cholecystitis if infection is involved.

13. An infant with congestive heart failure is receiving digoxin (Lanoxin). The nurse recognizes a sign of digoxin toxicity, which is: a. restlessness. b. decreased respiratory rate. c. increased urinary output. d. vomiting.

ANS: D Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse. DIF: Cognitive Level: Analysis REF: p. 618 OBJ: 5 TOP: Heart Failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

3. The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is blood pressure that is: a. higher on the right side. b. higher on the left side. c. lower in the arms than in the legs. d. lower in the legs than in the arms.

ANS: D The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation. DIF: Cognitive Level: Analysis REF: p. 615 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

necrotizing enterocolitis S/S? XR finding? Tx? Risk factors?

Bloody diarrhea XR: pneumocystis intestinalis (air in wall) Tx: NPO, TPN, antibiotics & resection of necrotic bowel Risk factors: prematurity, introduction of feeds, formula

17. Constipation in an elderly patient can be best treated by a. maintaining a low-fiber diet. b. maintaining the current level of activity. c. fecal disimpaction. d. increasing fiber in the diet.

ANS: D The presence of cellulose, the carbohydrate component of dietary fiber that is indigestible in the human intestine, may be effective in promoting regular peristaltic movement in the GI tract by forming bulk within the intestinal lumen to stimulate propulsion. Dietary factors, particularly a diet low in fiber, have been shown to contribute to constipation. In elderly persons the slowed rate of peristalsis that occurs with the aging process, coupled with a decreased level of physical activity, may promote chronic constipation. These factors may eventually contribute to the development of fecal impaction, a condition in which a firm, immovable mass of stool becomes stationary in the lower GI tract.

9. The most challenging aspect of treatment for chronic pancreatitis is a. pancreatectomy. b. strict dietary avoidance of fats. c. abstinence from alcohol. d. pain control.

ANS: D The treatment for chronic pancreatitis is directed toward pain control, exocrine and endocrine insufficiency, and management of complications. By far the most challenging is the management of pain. If endoscopic management fails or is not appropriate in a given patient, surgery may be indicated. Management of exocrine insufficiency can usually be accomplished with low-fat diets. Absolute abstention from alcohol is paramount to prevent worsening of symptoms.

7. A viral hepatitis screen with positive hepatitis B surface antigen (HBsAg) should be interpreted as ________ hepatitis B. a. recovered from b. immunity to c. chronic active d. acute

ANS: D With acute infection HBV core antigen (HBcAg) appears first, followed by seroconversion to core antibody (HBcAb). Presence of HBV surface antigen (HBsAg) indicates active infection. Conversion from surface antigen to surface antibody positivity can take as long as 1 year after acute infection. Development of surface antibody (HBsAb) points to resolution and immunity. In chronic infection, hepatitis B e antigen (HBeAg) is associated with viral replication and infectivity.

Which intervention is appropriate when examining a male infant for cryptorchidism? a. Cooling the examiner's hands b. Taking a rectal temperature c. Eliciting the cremasteric reflex d. Warming the room

ANS: D- Warming the room A. Examining the infant with cold hands is uncomfortable for the infant and likely to cause the infant's testes to retract into the inguinal canal. It may also cause the infant to be uncooperative during the examination. B. A rectal temperature yields no information about cryptorchidism. C. Testes can retract into the inguinal canal if the infant is upset or cold or if the cremasteric reflex is elicited. This can lead to an incorrect diagnosis. D. For the infant's comfort, the infant should be examined in a warm room with the examiner's hands warmed. Testes can retract into the inguinal canal if the infant is upset or cold.

20. The nurse is assessing a client diagnosed with cystitis. To percuss the kidneys, the nurse locates the costovertebral angle, which is formed by the spinal column and rib number:

Amswer 12; RATIONALES: Kidney percussion is done to check for costovertebral angle tenderness that occurs with inflammation. Percussing over the kidneys is done with the client sitting down. The nurse should place the ball of her nondominant hand on the client's back at the costovertebral angle — the angle formed by the spinal column and the 12th rib. The nurse should then strike the ball of her hand with the ulnar surface of her other hand and percuss bilaterally.

Leave a light on in the bathroom during the night.

An 82-year-old man has been admitted with benign prostatic hyperplasia. Which of the following is most appropriate to include in the nursing plan of care?

B (During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diapers because of risk of infection.)

An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include: a. Preparing the family for impending death. b. Teaching the family signs of central venous catheter infection. c. Teaching the family how to calculate caloric needs. d. Securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

50. A client is scheduled for a renal clearance test. The nurse should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in: 1. 1 minute. 2. 30 minutes. 3. 1 hour. 4. 24 hours.

Answer 1 RATIONALES: The renal clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. It doesn't measure the kidneys' ability to remove a substance over a longer period.

70. A client with suspected renal insufficiency is scheduled for a comprehensive diagnostic workup. After the nurse explains the diagnostic tests, the client asks which part of the kidney "does the work." Which answer is correct? 1. The glomerulus 2. Bowman's capsule 3. The nephron 4. The tubular system

Answer 3: RATIONALES: The nephron is the functioning unit of the kidney. The glomerulus, Bowman's capsule, and tubular system are components of the nephron.

89. A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? 1. Establishing a predetermined fluid intake pattern for the client 2. Encouraging the client to increase the time between voidings 3. Restricting fluid intake to reduce the need to void 4. Assessing present elimination patterns

Answer 4: RATIONALES: The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

40. The physician prescribes a single dose of trimethoprim/sulfamethoxazole (Bactrim) by mouth for a client diagnosed with an uncomplicated urinary tract infection (UTI). The pharmacy sends three unit-dose tablets. The nurse verifies the physician's order. What should the nurse do next? 1. Administer the three tablets as the single dose. 2. Call the physician to verify the order. 3. Give one tablet, three times per day. 4. Call the hospital pharmacist and question the medication supplied.

Answer 4: RATIONALES: The nurse should call the hospital pharmacy and question the medication supplied. The hospital pharmacist should be able to tell the nurse whether three tablets are necessary for the single dose or whether a dispensing error occurred. It isn't clear whether the three tablets are the single dose because they were packaged as a unit-dose. The physician order was clearly written, so clarifying the order with the physician isn't necessary. Administering the tablets without clarification might cause a medication error.

4) A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN) and is admitted to the hospital. Which is the priority nursing diagnosis for this child? 1. Risk for Injury related to hypertension. 2. Altered Growth and Development related to a chronic disease. 3. Risk for Infection related to hypertension. 4. Fluid Volume Excess related to decreased plasma filtration

Answer: 1 Explanation: 1. The child with APIGN has marked hypertension, which can lead to cardiac failure and cerebral injuries. 2. Growth and development are not normally affected because this is an acute process, not a chronic one. 3. While a risk for infection might be present, it is not related to the hypertension. 4. Although fluid retention occurs, this is not the priority diagnosis.

8) Which menu choices for a child who is diagnosed with renal failure and experiencing hyperkalemia indicate the need for further instruction by the nurse? 1. Carrots and green, leafy vegetables 2. Spaghetti and meat sauce with breadsticks 3. Hamburger on a bun and cherry gelatin 4. Chips, cold cuts, and canned foods

Answer: 1 Explanation: 1. Carrots and green, leafy vegetables are high in potassium. 2. Spaghetti and meat sauce with breadsticks would be acceptable choices for a low-potassium diet. 3. Hamburger on a bun with cherry gelatin would be acceptable choices for a low-potassium diet. 4. Chips, cold cuts, and canned foods are high in sodium but not necessarily in potassium.

7) The nurse is preparing medication instruction for a child who has undergone a kidney transplant and is prescribed cyclosporine. The parents ask the nurse about the reason for the cyclosporine. Which rationale for this medication should the nurse include in the response? 1. Suppress rejection 2. Decrease pain 3. Improve circulation 4. Boost immunity

Answer: 1 Explanation: 1. Cyclosporine is given to suppress rejection. 2. Cyclosporine does not decrease pain. 3. Cyclosporine does not affect circulation. 4. Cyclosporine does not boost immunity.

12) The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate? 1. Position the newborn in semi-Fowler position. 2. Allow the newborn to be taken to the mother's room for bonding. 3. Offer the newborn formula feeding instead of breastfeeding. 4. Wrap the newborn in blankets and place in a crib by the viewing window.

Answer: 1 Explanation: 1. This will reduce stomach juices from being aspirated into the lungs. 2. Because an anomaly is suspected, the newborn should remain under visualization until the diagnosis is confirmed and medical orders determined. 3. If an EA/TE fistula is suspected, the feeding should be withheld until the diagnosis is confirmed or cleared. 4. A newborn wrapped in blankets cannot be observed clearly. The child should be placed in an over-bed warmer.

21) Which are the leading causes of pediatric abdominal injuries for which the nurse should provide client teaching during scheduled health maintenance visits? Select all that apply. 1. Motor vehicle crashes 2. Falls 3. Blunt trauma 4. Stabbing 5. Impalement

Answer: 1, 2, 3 Explanation: 1. Motor vehicle crashes are a leading cause of pediatric abdominal injuries. The nurse should provide education related to proper use of seat belts during health maintenance visits to decrease the incidence of abdominal injuries. 2. Falls are a leading cause of pediatric abdominal injuries. The nurse should include education regarding age-appropriate pediatric fall prevention during health maintenance visits. 3. Blunt trauma is a leading cause of pediatric abdominal injuries. The nurse should include prevention strategies during health maintenance visits. 4. While stabbing can cause abdominal injury, this is not a common cause in the pediatric population. 5. While impalement can cause abdominal injury, this is not a common cause in the pediatric population.

20) Which nutritional interventions should the nurse include in the plan of care for a pediatric client who is receiving peritoneal dialysis in the treatment of chronic renal failure? Select all that apply. 1. Provide small, frequent meals. 2. Avoid battles over nutritional intake. 3. Administer supplements by tube feedings, if needed. 4. Implement hand hygiene frequently. 5. Perform daily catheter site care.

Answer: 1, 2, 3 Explanation: 1. The child will feel full with smaller amounts of food because of the dialysate. 2. The child will be more inclined to eat if there is less stress. 3. Adequate nutrition is important for growth and development, and must be supported if oral intake is inadequate. 4. This intervention is appropriate to prevent infection; it is not a nutritional intervention. 5. This intervention is appropriate to prevent infection; it is not a nutritional intervention.

18) Which actions should the nurse implement when assessing the physical growth for a child who is diagnosed with chronic renal failure? Select all that apply. 1. Asking the child to step on the scale 2. Measuring the child's height 3. Measuring the child's head circumference 4. Using the Denver II with the child 5. Monitoring the child's blood pressure

Answer: 1, 2, 3 Explanation: 1. Weight is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 2. Height is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 3. Head circumference is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 4. The Denver II is a developmental assessment tool. It is not used to assess physical growth. 5. Blood pressure is not a criterion used to measure physical growth.

12. A patient is admitted to the hospital with nephrotic syndrome after taking an OTC nonsteroidal antiinflammatory drug (NSAID) a week earlier. Which assessment data will the nurse expect to find related to this illness? a. Low blood pressure b. Recent weight gain c. Poor skin turgor d. High urine ketones

Answer: B Rationale: The patient with a rapid-onset nephrotic syndrome will have rapid weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Cognitive Level: Application Text Reference: p. 1167 Nursing Process: Assessment NCLEX: Physiological Integrity

12) Which risks of undescended testes should the nurse include in the teaching session for the parents of a newborn diagnosed with this condition? Select all that apply. 1. Sperm production will be affected after puberty. 2. Abdominal testes are subject to injury. 3. Abdominal testes have a higher risk of developing cancer. 4. Hormonal production will be affected. 5. The testes are at greater risk of torsion.

Answer: 1, 2, 3, 5 Explanation: 1. Sperm production by abdominal testes is affected by the heat of the body. 2. Positioning of the testes in the scrotum reduces the risk of injury. 3. Statistics have shown this statement is correct. 4. Production of hormones is not affected by the location of the testes. 5. Abdominal testes have a higher risk of twisting on its blood supply.

11. A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient? a. Fluid-volume excess related to low serum protein levels b. Altered nutrition: less than required related to protein restriction c. Activity intolerance related to increased weight and fatigue d. Disturbed body image related to peripheral edema and ascites

Answer: A Rationale: The patient has massive edema, so the priority problem at this time is the excess of fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites. Cognitive Level: Application Text Reference: pp. 1167-1168 Nursing Process: Diagnosis NCLEX: Physiological Integrity

23) Which factors in the maternal medical history should cause the nurse concern regarding the development of cleft lip or cleft palate during pregnancy? Select all that apply. 1. Cigarette smoking 2. Alcohol use 3. Excessive folate intake 4. Glucocorticoid use 5. Anticoagulant use

Answer: 1, 2, 4 Explanation: 1. Cigarette smoking during pregnancy is a risk factor for cleft lip and cleft palate. 2. Alcohol use during pregnancy is a risk factor for cleft lip and cleft palate. 3. Excessive folate intake is not a risk factor for cleft lip and cleft palate. A folate deficiency is often the cause for these disorders. 4. Glucocorticoid use is a risk factor for cleft lip and cleft palate. 5. Anticoagulant use is not a risk factor for cleft lip and cleft palate.

20) Which statements should the nurse include in a presentation related to the general function of the gastrointestinal (GI) system for parents of pediatric clients? Select all that apply. 1. "The GI tract is responsible for the ingestion and absorption of food." 2. "Newborns have smaller stomachs but increased peristalsis." 3. "All children require smaller, more frequent feedings." 4. "Infants lack certain digestive enzymes which increases the risk for regurgitation." 5. "By the second year of life a child is able to accommodate three meals each day."

Answer: 1, 2, 5 Explanation: 1. This statement is correct. The GI system is responsible for the ingestion and absorption of food. 2. This statement is correct. Newborns have smaller stomachs but an increased rate of peristalsis. 3. This statement is false. All children do not require smaller, more frequent feedings. This statement is true for newborns and infants. 4. This statement is false. While infants do lack certain digestive enzymes, this does not increase regurgitation but causes abdominal distention due to gas. 5. This statement is true. By the second year of life children are able to accommodate three

36. A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about a. the need to empty the bladder prior to treatment. b. premedicating to prevent nausea. c. the importance of oral care during treatment. d. where to obtain wigs and scarves.

Answer: A Rationale: The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not experienced with intravesical chemotherapy. Cognitive Level: Application Text Reference: p. 1180 Nursing Process: Implementation NCLEX: Physiological Integrity

22) Which topics should the nurse include in discharge instructions related to enhanced safety for a pediatric client who experienced an abdominal injury after a biking accident? Select all that apply. 1. Use of hand signals 2. Age-appropriate use of child safety seats 3. Age-appropriate bicycles 4. Use of a helmet 5. Avoid assigning blame

Answer: 1, 3, 4 Explanation: 1. Information related to appropriate hand signals when riding a bicycle is an injury prevention strategy that the nurse should include in the teaching session. 2. The use of an age-appropriate child safety seat is not an appropriate discharge instruction for a child who experienced an abdominal injury after a biking accident. 3. Information related to an age-appropriate bicycle is an injury prevention strategy that the nurse should include in the teaching session. 4. Information related to the use of a helmet is an injury prevention strategy that the nurse should include in the teaching session. 5. While the nurse should avoid assigning blame when providing care for a child who experienced an abdominal injury as a result of a biking accident, this is not an appropriate injury prevention topic to include in the discharge teaching session.

11) A neonate is born with a bilateral cleft lip that was not detected during the pregnancy. The parents are distressed about the appearance of their infant. Which nursing actions are appropriate to assist the parents to bond with their newborn? Select all that apply. 1. Calling the newborn by the chosen name 2. Keeping the newborn's lower face covered with the blanket 3. Smiling and talking to the newborn in the parents' presence 4. Showing the parents before and after pictures of other children with cleft lips 5. Discussing positive features of the baby

Answer: 1, 3, 4, 5 Explanation: 1. This behavior humanizes the child to the parents and is appropriate. 2. This indicates that the infant's appearance is distressing. Although the nurse would want to shield the child from a visitor's stare, the nurse would not want to hide the child from her own family. 3. This indicates acceptance of the infant by the nurse. 4. It is usually not appropriate to show before and after pictures as you cannot predict the success of the surgery on this child. But in the case of cleft lip, the improvement will be significant and it is considered acceptable to show before and after pictures. 5. Statements like, "Your baby is the sweetest thing—she never cries," can help the parents recognize positive features about their baby.

19) Which nursing actions are appropriate to assess growth and development for an adolescent client diagnosed with chronic renal failure? Select all that apply. 1. Using the Denver II during a health maintenance visit 2. Educating parents on normal milestones 3. Monitoring for delayed sexual maturation 4. Comparing blood pressure values from previous visit 5. Plotting height and weight measurements

Answer: 1, 3, 5 Explanation: 1. The Denver II is a developmental assessment tool that is appropriate for the nurse to use when assessing growth and development for an adolescent client diagnosed with chronic renal failure. 2. It is appropriate for the nurse to educate the client's parents on normal milestones; however, this is not a nursing assessment. 3. Monitoring for delayed sexual maturation is appropriate when assessing growth and development for an adolescent client diagnosed with chronic renal failure. 4. Blood pressure is not a growth and development parameter. 5. Plotting height and weight measurements is an appropriate nursing action to assess growth and development for an adolescent client diagnosed with chronic renal failure.

2. After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40 ml/hr, and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hr. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters does the nurse calculate as urine?

Answer: 1180 RATIONALES: During 8 hours, 1,600 ml of bladder irrigation has been infused (200 ml × 8 hr = 1,600 ml/8 hr). The nurse then subtracts this amount of infused bladder irrigation from the total volume in the drainage bag (2,780 ml − 1,600 ml = 1,180 ml) to determine urinary output.

5) Which laboratory tests should the nurse prepare to draw when admitting a pediatric client with possible obstructive uropathy? Select all that apply. 1. Platelet count 2. Blood urea nitrogen (BUN) 3. Partial thromboplastin time (PTT) 4. Blood culture 5. Creatinine

Answer: 2, 5 Explanation: 1. Platelet count is drawn when a bleeding disorder is suspected. 2. BUN is a serum laboratory test for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN will be elevated. 3. PTT is drawn when a bleeding disorder is suspected. 4. A blood culture is done when an infectious process is suspected. 5. Creatinine is a serum laboratory test for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the creatinine will be elevated.

- urinary output decreases to less than 400 ml per 24 hours - increase in BUN, creatinine, uric acid, potassium, and magnesium levels and presence of metabolic acidosis - 1-3 week duration

OLIGURIC PHASE

3) Which urinalysis result should the nurse anticipate for a child who is admitted with acute glomerulonephritis? 1. Bacteriuria and increased specific gravity 2. Hematuria and proteinuria 3. Proteinuria and decreased specific gravity 4. Bacteriuria and hematuria

Answer: 2 Explanation: 1. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present. But because the urine is concentrated, the specific gravity is increased. 2. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. The clinical manifestation of glomerulonephritis is grossly bloody hematuria with mild to moderate proteinuria, and because the urine is concentrated, the specific gravity is increased. 3. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Because the urine is concentrated, the specific gravity is increased. 4. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present.

14) Which statements, made by the adolescent following dietary teaching for Crohn disease, indicate correct understanding of the content presented by the nurse? Select all that apply. 1. "I can promote solid stools by increasing fiber in my diet." 2. "Small, frequent meals are preferred over three meals a day." 3. "I should identify foods that cause distress and eliminate them from my diet." 4. "High-calorie dietary supplement shakes can help me to meet my nutritional requirements." 5. "Socialization during my meal times is important even if my parents do not agree with my food choices."

Answer: 2, 3, 4 Explanation: 1. Fiber should be decreased, not increased, as diarrhea is one of the symptoms of Crohn disease. 2. This is correct information. 3. This is individualizing the diet and is appropriate. 4. This addition provides an easy way to meet the nutritional needs. 5. Stress should be avoided at mealtimes.

10) Which complications should the nurse monitor for when providing care to a child who is having hemodialysis for the treatment of kidney failure? Select all that apply. 1. Migraines 2. Hypotension 3. Infections 4. Fluid overload 5. Shock

Answer: 2, 3, 5 Explanation: 1. Migraines are not a clinical manifestation associated with hemodialysis. 2. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to hypotension. 3. Infection is another complication that may occur during hemodialysis. 4. Fluid overload is not a clinical manifestation associated with hemodialysis. 5. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to shock.

3. The nurse determines that instruction regarding prevention of future UTIs for a patient with cystitis has been effective when the patient states, a. "I will empty my bladder every 3 to 4 hours during the day." b. "I can use vaginal sprays to reduce bacteria." c. "I will wash with soap and water before sexual intercourse." d. "I will drink a quart of water or other fluids every day."

Answer: A Rationale: Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

14) Which instructions should be provided to the parents of a 4-year-old girl who has experienced chronic urinary tract infections (UTIs) in the last 2 years? Select all that apply. 1. Wear only nylon underwear for better air flow. 2. Teach the child to wipe from front to back. 3. Encourage the child to take long baths by allowing the child bubbles and toys in the tub. 4. Encourage the child to drink additional fluids throughout the day. 5. Plan potty breaks every 2 hours throughout the day.

Answer: 2, 4, 5 Explanation: 1. The child should wear cotton underwear. 2. This prevents bacteria from the rectum from being introduced into the urethra. 3. Bubble baths should be avoided. 4. Extra fluids will "wash" bacteria out of the bladder. 5. Children get so involved in playing that they often hold their urine. Voiding every 2 hours will reduce the time for bacteria to grow in the bladder.

19) The nurse is providing care to a newborn client who presents in the pediatric clinic for a 2-week health maintenance visit. The parents of the newborn are concerned, as their baby has "gas all the time." Which responses from the nurse are appropriate? Select all that apply. 1. "Your baby has a relaxed lower esophageal sphincter, which is causing the gas." 2. "Your baby lacks the enzyme amylase, which is causing the gas." 3. "Your baby lacks the enzyme insulin, which is causing the gas." 4. "Your baby has an immature liver, which is causing the gas." 5. "Your baby lacks an enzyme that helps to digest fats, which is causing the gas."

Answer: 2, 5 Explanation: 1. Newborns and infants do have a relaxed lower esophageal sphincter; however, this is not responsible for gas but for frequent regurgitation of small amounts of oral feedings. 2. Newborns and infants lack several enzymes that assist with the digestive process. One of these enzymes is amylase, which assists with carbohydrate digestion. The lack of this enzyme causes abdominal distention due to gas. 3. Insulin is not an enzyme and is not lacking in the newborn. 4. While newborns and infants do have immature livers, that is not what is causing the gas. 5. Lipase is a digestive enzyme that assists in fat digestion. Infants and newborns do lack this enzyme, which would cause abdominal distention due to gas.

5) Which is the priority nursing diagnosis when planning care for a newborn who is born with esophageal atresia and tracheoesophageal fistula? 1. Ineffective Tissue Perfusion 2. Ineffective Infant Feeding Pattern 3. Acute Pain 4. Risk for Aspiration

Answer: 4 Explanation: 1. Tissue perfusion is not a primary problem with this condition. 2. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. 3. Pain is not usually experienced preoperatively with this condition. 4. This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea.

22. When obtaining the health history for a 30-year-old patient who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for a. interstitial cystitis. b. UTI. c. kidney stones. d. bladder cancer.

Answer: D Rationale: Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, UTI, or kidney stones will not be reduced by quitting smoking. Cognitive Level: Application Text Reference: p. 1178 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

52. A client develops decreased renal function and requires a change in antibiotic dosage. On which factor would the physician base the dosage change? 1. GI absorption rate 2. Therapeutic index 3. Creatinine clearance 4. Liver function studies

Answer: 3 RATIONALES: The physician orders tests for creatinine clearance to gauge the kidney's glomerular filtration rate; this is important because most drugs are excreted at least partially by the kidneys. The GI absorption rate, therapeutic index, and liver function studies don't help determine dosage change in a client with decreased renal function

15) Which is the priority nursing intervention when caring for a neonate who is born with bladder exstrophy? 1. Measuring intake and output 2. Inserting a Foley catheter 3. Covering the defect with sterile plastic wrap 4. Palpating the bladder mass to ensure urine is expelled

Answer: 3 Explanation: 1. Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible. 2. The bladder is open to the abdomen. A Foley catheter cannot be inserted. 3. This reduces the contamination of the bladder, which should be sterile. 4. The bladder is very sensitive and palpation would cause unnecessary pain.

6) Which clinical manifestations should the nurse anticipate upon assessment for a preschool-age child with a urinary tract infection (UTI)? 1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure (BP), and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache

Answer: 3 Explanation: 1. Hematuria might be present, but there will be no complaints of headache or vertigo. 2. While foul-smelling urine and hematuria can be present, there is no elevated BP, headache, or vertigo. 3. Clinical manifestations of UTI in a preschool-age child include fever, urgency, and dysuria. 4. There could be flank pain, although the preschooler might be unable to describe it. There will be no complaints of headache.

21) Which interventions should the nurse include in the plan of care for a pediatric client who is receiving peritoneal dialysis in the treatment of chronic renal failure to prevent infection? Select all that apply. 1. Provide small, frequent meals. 2. Avoid battles over nutritional intake. 3. Administer supplements by tube feedings, if needed. 4. Implement hand hygiene frequently. 5. Perform daily catheter site care.

Answer: 3, 4 Explanation: 1. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 2. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 3. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 4. Aseptic technique reduces chance of introducing bacteria into the abdomen. 5. Skin around the catheter site will have fewer organisms that could potentially cause infection.

18) Which gastrointestinal defects, often diagnosed shortly after birth, should the nurse include in the assessment process of all newborns? Select all that apply. 1. Pyloric stenosis 2. Biliary atresia 3. Hirschsprung disease 4. Umbilical hernia 5. Diaphragmatic hernia

Answer: 3, 5 Explanation: 1. Pyloric stenosis is not diagnosed in the newborn nursery, but in the 2- to 4-week-old infant. 2. Symptoms of biliary atresia would not be observable until several weeks of age. 3. Symptoms of Hirschsprung disease may be observable in the newborn nursery. 4. Umbilical hernia cannot be diagnosed at birth. 5. Diaphragmatic hernia will show symptoms immediately after birth due to compression of the lung.

16) Which clean-catch urinalysis finding should the nurse be most concerned for a child who is admitted to an urgent care center to rule out a urinary tract infection? 1. 2+ white blood cells 2. 1+ red blood cells 3. Urine appearance: cloudy 4. Specific gravity: 1009

Answer: 4 Explanation: 1. White blood cells are expected. 2. Red blood cells are common in the urine of a child with a urinary tract infection. 3. With white blood cells in the urine, this is a common finding. 4. This is a very dilute urine. With white blood cells (WBCs), red blood cells (RBCs), and bacteria in the urine, you would expect the urine to contain more solutes.

Which issue is important to discuss when educating a family about nocturnal enuresis? a. Limit daytime fluids. b. Have the child double-void before going to bed. c. Administer laxatives daily. d. Refer the child to counseling immediately.

Answer: b. Have the child double-void before going to bed. Feedback: Counseling is not always indicated. Promoting regular stools and having the child double-void before bed are appropriate interventions. Limiting daytime fluids has not been shown to be effective.

1) The nurse is providing care to a pediatric client, diagnosed with inflammatory bowel disease, who is prescribed daily prednisone. Which parental statement regarding administration of this drug indicates correct understanding of the teaching provided by the nurse? 1. "I will administer this medication between meals." 2. "I will administer this medication at bedtime." 3. "I will administer this medication one hour before meals." 4. "I will administer this medication with meals."

Answer: 4 Explanation: 1. Prednisone can cause gastric irritation and should not be given on an empty stomach. 2. Prednisone can cause gastric irritation and should not be given before bedtime on an empty stomach. 3. Prednisone can cause gastric irritation and should not be given on an empty stomach one hour before meals. 4. Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

14. A patient with a history of renal calculi is hospitalized with gross hematuria and severe colicky left flank pain that radiates to his left testicle. In planning care for the patient, the nurse gives the highest priority to the nursing diagnosis of a. acute pain related to irritation by the stone. b. deficient fluid volume related to inadequate intake. c. risk for infection related to urinary system damage. d. risk for nausea related to pain and renal colic.

Answer: A Rationale: Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of the acute pain. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Diagnosis NCLEX: Physiological Integrity

4) The nurse is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate? 1. Measuring the girth just below the umbilicus 2. Measuring the girth just below the sternum 3. Measuring the girth just above the pubic bone 4. Measuring the girth around the portion of the stomach

Answer: 4 Explanation: 1. The circumference below the umbilicus would not be an accurate abdominal girth. 2. The circumference just below the sternum would not be an accurate abdominal girth. 3. The circumference just above the pubic bone would not be an accurate abdominal girth. 4. An abdominal girth should be taken around the largest circumference of the abdomen, just above the umbilicus.

9) A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse have on hand for the delivery? 1. Bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Endotracheal tube

Answer: 4 Explanation: 1. A bag-valve-mask system, or Ambu bag, could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing. 2. The defect is not external, so sterile gauze and saline are not needed. 3. Soft arm restraints might be necessary but at are not an immediate concern. 4. A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized.

7) The nurse is planning care for a school-age client who is postoperative for the surgical removal of the appendix. In addition to pharmacologic pain management, which should the nurse include in the plan of care to address pain? 1. Applying a warm, moist pack every 4 hours 2. Applying EMLA cream to the incision site prior to ambulation 3. Applying a cold, moist pack every 2 hours 4. Applying a pillow against the abdomen to splint the incision site when coughing

Answer: 4 Explanation: 1. Heat and moisture are not used on the incision area, as they can impair the healing process of the wound. 2. EMLA cream is a medication that requires a prescription. 3. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. 4. A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy.

9) Which parental statement indicates understanding of the process involved with a kidney transplant for a child with renal failure? 1. "We are happy our child will not have to take any more medicine after the transplant." 2. "We understand our child will not be at risk anymore for catching colds from other children at school." 3. "We will be glad we will not have to bring our child in to see the doctor again." 4. "We know it is important to see that our child takes prescribed medications after the transplant."

Answer: 4 Explanation: 1. Medications and general health promotion will be necessary. 2. The child will be on immunosuppressing drugs and will be at increased risk for colds and other illnesses. 3. Follow-up appointments will be necessary, as well as medications and general health promotion. 4. It is important that the nurse emphasizes compliance with treatments that will need to be followed after the transplant.

Which assessment finding would lead the nurse to suspect esophageal atresia in an infant? a. Hypotonicity b. Excessive crying c. Abdominal distention d. Excessive drooling

Answer: d. Excessive drooling Feedback: The classic symptoms in an infant with esophageal atresia are excessive drooling often accompanied by cyanosis, choking, and coughing. Low blood pressure, excessive crying, and hypotonicity are not common signs of esophageal atresia.

1. When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. flank pain. b. pain with urination. c. poor urine output. d. nausea.

Answer: B Rationale: Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Assessment NCLEX: Physiological Integrity

8. When admitting a patient with acute glomerulonephritis, the nurse will ask the patient about a. history of high blood pressure. b. frequency of UTIs. c. recent sore throat and fever. d. family history of kidney disease.

Answer: C Rationale: Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, UTI, or related to family history. Cognitive Level: Application Text Reference: p. 1165 Nursing Process: Assessment NCLEX: Physiological Integrity

4. To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests that the patient use the OTC urinary analgesic phenazopyridine (Pyridium) but cautions the patient that this preparation a. contains methylene blue, which turns the urine blue or green. b. should be taken on an empty stomach for maximum effect. c. causes the urine to turn reddish orange and can stain underclothing. d. frequently causes allergic reactions and should be stopped if a rash occurs.

Answer: C Rationale: Patients should be taught that Pyridium will color the urine deep orange and stain underclothing. Urised may turn the urine blue or green. The medication can cause gastrointestinal distress and should be taken with food. Although an allergic reaction may occur, this is not common. Cognitive Level: Comprehension Text Reference: p. 1158 Nursing Process: Implementation NCLEX: Physiological Integrity

9. The nurse establishes a nursing diagnosis of excess fluid volume related to inflammation at the glomerular basement membrane in a patient with acute glomerulonephritis. To best evaluate whether the problem identified in the nursing diagnosis has resolved, the nurse will monitor for a. proteinuria. b. elevated creatinine. c. periorbital edema. d. hematuria.

Answer: C Rationale: Resolution of the excess fluid volume is best evaluated by changes in edema. The other data may indicate whether the glomerulonephritis is resolving but do not provide data about fluid volume. Cognitive Level: Application Text Reference: p. 1165 Nursing Process: Evaluation NCLEX: Physiological Integrity

35. The nurse working in a urology clinic receives a call from a patient who had a transurethral resection with fulguration for bladder cancer 3 days previously. Which information given by the patient is of most concern to the nurse? a. The patient is voiding every 4 hours at night. b. The patient is using opioids for pain. c. The patient is very anxious about the cancer. d. There are clots in the urine.

Answer: D Rationale: Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure. Cognitive Level: Application Text Reference: p. 1179 Nursing Process: Assessment NCLEX: Physiological Integrity

28. After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective? a. "I will need to buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will need to take prophylactic antibiotics to prevent any urinary tract infections." d. "I will wash the catheter with soap and water before and after each catheterization."

Answer: D Rationale: Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

21. When assessing a patient who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of a. recurrent renal calculi. b. kidney trauma. c. bladder infection. d. gonococcal urethritis.

Answer: D Rationale: The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with renal calculi, kidney trauma, or bladder infection. Cognitive Level: Application Text Reference: p. 1174 Nursing Process: Assessment NCLEX: Physiological Integrity

B (Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The child's diet should be supplemented with potassium. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1333 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity)

As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: a. Chlorides. b. Potassium. c. Sodium. d. Vitamins.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? A Unstable angina B Acute coronary syndrome (ACS) C ST-segment-elevation myocardial infarction (STEMI) D Non-ST-segment-elevation myocardial infarction (NSTEMI)

B Rationale: The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? A Sinus tachycardia B Pathologic Q wave C Fibrillatory P waves D Prolonged PR interval

B Rationale: The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A "I will replace my nitroglycerin supply every 6 months." B "I can take up to five tablets every 3 minutes for relief of my chest pain." C "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B Rationale: The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

Which consideration is the most important in managing tuberculosis (TB) in children? a. Skin testing annually b. Pharmacotherapy c. Adequate nutrition d. Adequate hydration

B Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and two or three times a week for the remaining 4 months. Pharmacotherapy is the most important intervention for TB

The nurse is assessing a child with acute epiglottitis. Examining the child's throat by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction c. Sore throat d. Respiratory tract infection

B If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.

The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include: a. forcing fluids. b. monitoring pulse oximetry. c. instituting seizure precautions. d. encouraging a high-protein diet.

B Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful.

A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease (DNase). Which is an adverse effect of this medication? a. Mucus thickens b. Voice alters c. Tachycardia d. Jitteriness

B One of the only adverse effects of DNase is voice alterations and laryngitis. DNase decreases viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12 years. β2 agonists can cause tachycardia and jitteriness.

A nurse is admitting an infant with asthma. The nurse understands that asthma in infants is usually triggered by: a. medications. b. a viral infection. c. exposure to cold air. d. allergy to dust or dust mites.

B Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease.

A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A chest tube has been inserted to promote continuous closed chest drainage. Which interventions should the nurse implement when caring for this child? (Select all that apply.) a. Positioning child on the right side b. Assessing the chest tube and drainage device for correct settings c. Administering prescribed doses of analgesia d. Clamping the chest tube when child ambulates e. Monitoring for need of supplemental oxygen

B, C, E Nursing care of the child with a chest tube requires close attention to respiratory status; the chest tube and drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube insertion site is intact, water seal is maintained, and chest tube remains in place). Movement in bed and ambulation with a chest tube are encouraged according to the child's respiratory status, but children require frequent doses of analgesia. Supplemental oxygen may be required in the acute phase of the illness and may be administered by nasal cannula, face mask, flow-by, or face tent. The child should be positioned on the left side, not the right. Lying on the affected side if the pneumonia is unilateral ("good lung up") splints the chest on that side and reduces the pleural rubbing that often causes discomfort. The chest tube should never be clamped; this can cause a pneumothorax. The chest tube should be maintained to the underwater seal at all times.

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? A Flushing B Ashen skin C Diaphoresis D Nausea and vomiting E S3 or S4 heart sounds

B,C,D,E Rationale: During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? A Niacin (Nicobid) B Ezetimibe (Zetia) C Gemfibrozil (Lopid) D Atorvastatin (Lipitor) E Cholestyramine (Questran)

B,D Rationale: Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

To evaluate the effectiveness of treatment for the patient with nephrotic syndrome, you assess the A. Blood pressure q4h B. Abdominal girth daily C. Urine of each voiding for protein D. Daily dietary protein intake

B. Abdominal girth daily A major nursing intervention for a patient with nephrotic syndrome is related to edema. It is important to assess the edema by weighing the patient daily, accurately recording intake and output, and measuring abdominal girth or extremity size. Comparing this information daily provides you with a tool for assessing the effectiveness of treatment.

The highest priority nursing intervention for a child hospitalized with respiratory infection and cystic fibrosis would be: A. Manning strict i&o B. Administering intravenous antibiotics C. Recording vital signs every 4 hrs D. Arranging for sweat chloride testing

B. Administering intravenous antibiotics

A child presents to the emergency department in acute respiratory distress caused by an asthmatic episode. Which of the following drugs would then nurse plan to administer first A. Prednisone B. Albuterol C. Theophylline D. Cromolyn sodium

B. Albuterol

What are the immunologic mechanisms involved in glomerulonephritis? A. Tubular blocking by precipitates of bacteria and antibody reactions B. Deposition of immune complexes and complement along the glomerular basement membrane (GBM) C. Thickening of the GBM from autoimmune microangiopathic changes D. Destruction of glomeruli by proteolytic enzymes contained in the GBM

B. Deposition of immune complexes and complement along the glomerular basement membrane (GBM) All forms of immune complex disease are characterized by an accumulation of antigen, antibody, and complement in the glomeruli, which can result in tissue injury. The immune complexes activate complement. Complement activation results in the release of chemotactic factors that attract polymorphonuclear leukocytes, histamine, and other inflammatory mediators. The result of these processes is glomerular injury.

What clinical manifestations would the nurse expect to find in a newborn who has developed necrotizing enterocolitis (NEC)? A. Hyperthermia B. Gastric residual and melena C. The passage of ribbon-like stools D. Projectile vomiting

B. Gastric residual and melena The most prominent signs of NEC are abdominal distention, gastric residuals, and blood in the stools (melena). NEC resembles septicemia; the newborn may "not look well," in addition to having nonspecific signs such as lethargy, poor feeding, hypotension, hypothermia, bile-stained vomitus, and oliguria.The newborn with NEC is more likely to be seen with hypothermia, not hyperthermia.The passage of ribbon-like stools is seen in newborns and infants born with Hirschsprung disease.Projectile vomiting is seen in newborns and infants with pyloric stenosis.

A 6-month-old infant is being evaluated for bradycardia. Which is the most likely cause of the bradycardia? A. Hypovolemia B. Hypoxia C. Drug toxicity D. Hyperglycemia

B. Hypoxia

Which medication usually is prescribed for patients with nephrotic syndrome? A. Sulfa B. Prednisone C. Amoxicillin D. Sulfisoxazole

B. Prednisone Corticosteroids and cyclophosphamide (Cytoxan) may be used for the treatment of severe cases of nephrotic syndrome. Prednisone has been effective to various degrees in persons with early-stage nephrosis, membranous glomerulonephritis, proliferative glomerulonephritis, and lupus nephritis.

What constituent is expected when evaluating the urinalysis of a patient with acute glomerulonephritis? A. Microscopic calculi B. Red blood cells and protein C. Escherichia coli D. Platelets

B. Red blood cells and protein Dipstick urinalysis and urine sediment microscopy reveal the presence of erythrocytes in significant numbers. Erythrocyte casts are highly suggestive of APSGN. Proteinuria may range from mild to severe. Screening blood tests include BUN and serum creatinine levels to assess the extent of renal impairment.

The nurse is giving discharge instruction to the parents of a toddler with asthma. What information is essential to include? A. Take prescribed medications weekly to control asthma symptoms. B. Remove mold, animal dander, dust, and cockroach particles from the child's surroundings. C. Use commercial air freshers to neutralize the smell of cigarette smoke in the home D. For adequate nutrition include cows milk, egg, peanuts, and wheat products in the diet

B. Remove mold, animal dander, dust, and cockroach particles from the child's surroundings.

What is a priority nursing diagnosis for the patient with nephrotic syndrome? A. Activity intolerance B. Risk for infection C. Decreased cardiac output D. Imbalanced nutrition: less than body requirements

B. Risk for infection The patient with nephritic syndrome is susceptible to infection and should take measures to avoid exposure to persons known to have infections.

The mother of a child diagnosed with pyelonephritis asks if the kidneys were damaged because of this. What is the best response by the nurse? a) Yes, all children who get pyelonephritis have renal scarring. b) The child's risk for renal scarring is increased with pyelonephritis. c) As long as IV antibiotics are started, there is no risk of renal damage. d) No, if the child is urinating normally, the kidneys were not damaged.

B. The child's risk for renal scarring is increased with pyelonephritis. Correct Explanation: It would not be possible to determine if the child has renal scarring with pyelonephritis until more testing is performed. It can result in renal scarring with this type of problem, but that does not mean there will definitely be complications. Antibiotics are usually the treatment of choice in this situation, but it cannot be determined when the damage had occurred.

The diagnosis of urethral diverticula is confirmed by which diagnostic test? A. Blood urea nitrogen (BUN) B. Voiding cystourethrography (VCUG) C. Intravenous pyelogram (IVP) D. Cystoscopy

B. Voiding cystourethrography (VCUG) When palpated, urethral diverticula may be quite tender and express a purulent discharge through the urethra. Radiographic studies such as VCUG should be used to confirm the diagnosis. Additional studies include ultrasound and magnetic resonance imaging (MRI) to determine the size of the diverticulum in relation to the urethral lumen.

A 4-year-old child has ingested a toxic dose of iron. The parent reports that the child vomited and complained of gastric pain an hour ago but "feels fine" now. The parent is not certain when the child ingested the iron tablets. The most appropriate recommendation by the nurse to the parent is to A. observe the child closely for 2 more hours. B. bring the child to the hospital immediately. C. administer activated charcoal. D. administer ipecac to induce vomiting if the child does not vomit again within 1 hour.

B. bring the child to the hospital immediately. The child should be transported to the hospital immediately for assessment and possible gastric lavage.The period of concern for complications of iron toxicity is from 30 minutes to 6 hours.Activated charcoal does not bind iron and, therefore, is not a course of treatment for this child.Ipecac is not recommended for poisonings.

patient's bowel sounds.

Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the ______________

serum phosphate.

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for _______________

Intestinal atresia S/S? Causes? (and common XR finding) Associated w/?

Bilious vomiting Duodenal atresia: "double bubble" on XR Annular pancreas Ass. with: Down's syndrome (esp. duodenal atresia)

Malrotation and Volvulus S/S? Path?

Bilious vomiting, draws up legs, ABD distention Path: gut does not rotate 270 ccw around SMA (Ladd's bands can kink the duodenum)

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? A Dehydration B Paralytic ileus C Atrial dysrhythmias D Acute respiratory distress syndrome

C Rationale: Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? A Palpate the insertion site for induration. B Assess peripheral pulses in the right leg. C Inspect the patient's right side and back. D Compare the color of the left and right legs.

C Rationale: The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? A "What precipitated the pain?" B "Has the pain changed this time?" C "In what areas did you feel this pain?" D "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

C Rationale: Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

It is generally recommended that a child with acute streptococcal pharyngitis can return to school: a. when sore throat is better. b. if no complications develop. c. after taking antibiotics for 24 hours. d. after taking antibiotics for 3 days.

C After children have taken antibiotics for 24 hours, they are no longer contagious to other children. Sore throat may persist longer than 24 hours after beginning antibiotic therapy, but the child is no longer considered contagious. Complications may take days to weeks to develop.

A child is diagnosed with influenza, probably type A disease. Management includes which recommendation? a. Clear liquid diet for hydration b. Aspirin to control fever c. Amantadine hydrochloride (Symmetrel) to reduce symptoms d. Antibiotics to prevent bacterial infection

C Amantadine hydrochloride may reduce symptoms related to influenza A if administered within 24 to 48 hours of onset. It is ineffective against type B or C. A clear liquid diet is not necessary for influenza, but maintaining hydration is important. Aspirin is not recommended in children because of increased risk of Reye syndrome. Acetaminophen or ibuprofen is a better choice. Preventive antibiotics are not indicated for influenza unless there is evidence of a secondary bacterial infection.

Which drug is considered the most useful in treating childhood cardiac arrest? a. Bretylium tosylate (Bretylium) b. Lidocaine hydrochloride (Lidocaine) c. Epinephrine hydrochloride (Adrenaline) d. Naloxone (Narcan)

C Epinephrine works on alpha and beta receptors in the heart and is the most useful drug in childhood cardiac arrest. Bretylium is no longer used in pediatric cardiac arrest management. Lidocaine is used for ventricular arrhythmias only. Naloxone is useful only to reverse effects of opioids.

A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent has understood the teaching if which statement is made? a. "I will record the average of the readings." b. "I should be sitting comfortably when I perform the readings." c. "I will record the readings at the same time every day." d. "I will repeat the routine two times."

C Instructions for use of a peak flowmeter include standing up straight before performing the reading, recording the highest of the three readings (not the average), measuring the peak expiratory flow rate (PEFR) close to the same time each day, and repeating the entire routine three times, waiting 30 seconds between each routine.

It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because which disease or assessment findings may develop? a. Cough b. Osteoporosis c. Slowed growth d. Cushing syndrome

C The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids.

What is a common urinary diversion that results in a stoma and the need for an ostomy pouch? A. Indian pouch B. Kock reservoir C. Ileal or colon conduit D. Continent ileal reservoir

C. Ileal or colon conduit The most commonly performed incontinent urinary diversion procedure is the ileal conduit (ileal loop). In this procedure, a 6- to 8-inch (15- to 20-cm) segment of the ileum is converted into a conduit for urinary drainage. The colon (colon conduit) can be used instead of the ileum. The ureters are anastomosed into one end of the conduit, and the other end of the bowel is brought out through the abdominal wall to form a stoma.

A teenager with chronic asthma asks the nurse, "How come I make so much noise when I breath?" The nurses best reply is: A. It is the sound of the air passing through fluid in your alveoli B. It is the sound of air passing through fluid in your bronchus C. It is the sound of air being pushed through narrowed bronchi on expiration D. It is the sound of air being pushed past a narrowed larynx on expiration

C. It is the sound of air being pushed through narrowed bronchi on expiration

A young child is diagnosed with vesicoureteral reflux. What would the nurse expect to read in the medical history that the child had been experiencing? A. Incontinence B. Hypotension C. Recurrent kidney infections D. Increased renal arterial perfusion

C. Recurrent kidney infections Reflux allows urine flow to be forced back to the kidneys. When the urine is infected, this contributes to kidney infections.

The mother of an infant diagnosed with bronchiolitis asks the nurse what causes this disease. The nurse's response would be based on the knowledge that the majority of infections that cause bronchiolitis area a result of: A. Ribavinin B. Mycoplasma pneumonia (MP) C. Respiratory distress syndrome (RSV) D. Hemophilia influenzae

C. Respiratory distress syndrome (RSV)

Which of the following might a child with asthma be advise to avoid? A. Swimming B. Gymnastics C. Snow skiing D. Playgrounds

C. Snow skiing

An 18-month-odl child is seen in the emergency department with a "seal bark" cough, loud raspy breathing, and chest wall retractions with use of accessory muscles. He is admitted with a diagnosis of Laryngotracheobronchitis. Following the initial workup, the toddler is still short of breath but is rubbing his eyes as if he is sleepy. The mother wants to lay the toddler down for his nap. The child refuses to lie down. The nurse should suggest. A. Rocking eh child until he is asleep and then lay him down B. The mother swaddle the child and lay him in her lap C. The mother allow the child to sleep in an upright position D. A sleeping pill to help the child rest

C. The mother allow the child to sleep in an upright position

Why are renal tumors often difficult to diagnose? A. They do not show up on routine radiologic examinations. B. They mimic the pain associated with renal stones. C. They lack significant clinical manifestations. D. They are rare and occur unilaterally.

C. They lack significant clinical manifestations. Because there are no characteristic early symptoms of kidney cancer, many patients go undiagnosed until the disease has significantly progressed.

The most critical intervention in the prevention of renal calculi is for the patient to A. urinate frequently. B. eat a diet high in protein. C. maintain a high fluid intake. D. eliminate all calcium from the diet.

C. maintain a high fluid intake. The most important factor in the prevention of renal calculi is keeping urine dilute and free flowing. This reduces the risk of recurrent stone formation in many individuals. This is accomplished by drinking about 2000 to 2200 mL/day, with the residual 20% to 30% of fluids gained through consumption of foods. The volume of fluids is higher in the highly active patient who works outdoors or who regularly engages in demanding athletic activities.

The nursing activity "encourage increased fluid intake" is beneficial to patients with any type of urinary tract infection because it A. decreases residual urine. B. prevents urinary reflux. C. prevents urinary stasis. D. alters urinary pH.

C. prevents urinary stasis. Acute intervention for a patient with a UTI includes ensuring adequate fluid intake if it is not contraindicated. It is sometimes difficult to get the patient to maintain an adequate fluid intake because the person may think it will worsen the discomfort and frequency associated with a UTI. Tell patients that fluids will increase frequency of urination at first but will also dilute the urine, making the bladder less irritable. Fluids help to flush out bacteria before they have a chance to colonize in the bladder.

D (Hepatitis A is spread person to person, by the fecal-oral route, and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis is not infectious. Cirrhosis is not infectious.)

Careful hand washing before and after contact can prevent the spread of which condition in day care and school settings? a. Irritable bowel syndrome b. Hepatic cirrhosis c. Ulcerative colitis d. Hepatitis A

D (Using special or modified nipples for feeding techniques helps to meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and nonnutritive sucking.)

Caring for the newborn with a cleft lip and palate before surgical repair includes: a. Gastrostomy feedings. b. Keeping the infant in near-horizontal position during feedings. c. Allowing little or no sucking. d. Providing satisfaction of sucking needs.

B (Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies, or emotional factors. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.)

Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies, which are now being successfully treated with antihistamines. The nurse should suspect that the constipation is most likely caused by: a. Diet. b. Antihistamines. c. Allergies. d. Emotional factors.

dialysate is infused into the abdomen and remains there 2-6 hours. The dialysate is removed by gravity drainage after the prescribed time

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Which frequency is recommended for childhood skin testing for tuberculosis (TB) using the Mantoux test? a. Every year for all children older than 2 years b. Every year for all children older than 10 years c. Every 2 years for all children starting at age 1 year d. Periodically for children who reside in high-prevalence regions

D Children who reside in high-prevalence regions for TB should be tested every 2 to 3 years. Annual testing is not necessary. Testing is not necessary unless exposure is likely or an underlying medical risk factor is present

Which drug is usually given first in the emergency treatment of an acute, severe asthma episode in a young child? a. Ephedrine b. Theophylline c. Aminophylline d. Short-acting β2 agonists

D Short-acting β2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations. Aminophylline is not helpful for acute asthma exacerbation.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? A Baked flounder B Angel food cake C Baked potato with margarine D Canned chicken noodle soup

D Rational: Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A Chronic stable angina B Left-sided heart failure C Coronary artery disease D Acute myocardial infarction

D Rationale: PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

Pancreatic enzymes are administered to the child with cystic fibrosis (CF). Nursing considerations should include to: a. not administer pancreatic enzymes if child is receiving antibiotics. b. decrease dose of pancreatic enzymes if child is having frequent, bulky stools. c. administer pancreatic enzymes between meals if at all possible. d. pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.

D Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage of enzymes should be increased if child is having frequent, bulky stools. Enzymes should be given just before meals and snacks.

A school nurse is trying to prevent poststreptococcal glomerulonephritis in children. Which of the following would be the best way to prevent this? a) Prophylactic antibiotics after strep throat are important. b) Tell parents to give ibuprofen if their child has a sore throat. c) All children in the child's class should be tested for strep throat if there is a positive. d) Encourage the child to take all the antibiotics if diagnosed with strep throat.

D)Encourage the child to take all the antibiotics if diagnosed with strep throat. Correct Explanation: Encouraging the child to take all the antibiotics if diagnosed with strep throat is important. It is not necessary to test the people in the community that the child came in contact with unless they are symptomatic. Ibuprofen does not cure strep throat and that is what usually causes poststreptococcal glomerulonephritis. Prophylactic antibiotics after a strep infection are not necessary.

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child's care? (Select all that apply.) a. Place in a mist tent. b. Administer antibiotics. c. Administer cough syrup. d. Encourage to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring.

D, E, F Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes. Cough syrup suppresses clearing of respiratory secretions and is not indicated for young children.

You are providing care for a patient who has been admitted to the hospital for the treatment of nephrotic syndrome. What is a priority nursing assessment in the care of this patient? A. Assessment of pain and level of consciousness B. Assessment of serum calcium and phosphorus levels C. Blood pressure and assessment for orthostatic hypotension D. Daily weights and measurement of the patient's abdominal girth

D. Daily weights and measurement of the patient's abdominal girth Peripheral edema is characteristic of nephrotic syndrome, and a key nursing responsibility in the care of patients with the disease is close monitoring of abdominal girth, weight, and extremity size. Pain, level of consciousness, and blood pressure are less important in the care these patients. Abnormal calcium and phosphorus levels are not commonly associated with nephrotic syndrome.

What causes the edema that occurs in nephrotic syndrome? A. Increased hydrostatic pressure caused by sodium retention B. Decreased aldosterone secretion from adrenal insufficiency C. Increased fluid retention caused by decreased glomerular filtration D. Decreased colloidal osmotic pressure caused by loss of serum albumin

D. Decreased colloidal osmotic pressure caused by loss of serum albumin The increased glomerular membrane permeability found in nephrotic syndrome is responsible for the massive excretion of protein in the urine. This results in a decreased serum protein level and subsequent edema formation. Ascites and anasarca (massive generalized edema) develop if there is severe hypoalbuminemia.

The nurse providing education for the patient with polycystic kidney disease (PKD) should include what in the teaching plan? A. Measurement of blood pressure B. Performance of sterile self-catheterization C. Avoidance of beverages containing caffeine D. Early recognition of the signs of infection or bleeding

D. Early recognition of the signs of infection or bleeding There is no specific treatment for PKD. A major aim of treatment is to prevent infections of the urinary tract and to treat them with appropriate antibiotics if they occur.

Which factor in the patient's history is most commonly associated with nephrosclerosis? A. Renal calculi B. Frequent UTIs C. Congenital nephritis D. Essential hypertension

D. Essential hypertension Nephrosclerosis is caused by vascular changes resulting from hypertension and from the atherosclerosis process.

A child with a respiratory infection is scheduled to have a sweat test. The mother asks the purpose of the diagnostic test. The nurse's response would be based on the knowledge that the test: A. Determines if the chid is dehydrated B. Assesses if the sweat glands are functioning C. Identifies the infectious organism D. Establishes a diagnosis of cystic fibrosis

D. Establishes a diagnosis of cystic fibrosis

A chid is brough to the emergency department with suspected epiglottis. Which nursing intervention would be considered unsafe? A. Allowing the child to remain in the position of choice. B. Placing intubation equipment at the bedside C. Encouraging parens to comfort the child D. Examining the throat

D. Examining the throat

Which assessment finding is associated with renal calculi? A. Urinary bladder distention B. Hypertension C. Proteinuria D. Flank pain

D. Flank pain Clinical manifestations of renal calculi include abdominal or flank pain (typically severe), hematuria, and renal colic.

A 6-year-old client with CF is preparing to eat breakfast. What is the most important piece of information the nurse would want before the child eats? A. Whether the meal is exactly what he ordered B. If he plans to eat all of it C. When he ate last D. If he has taken his enzymes

D. If he has taken his enzymes -need to take if with every meal/snack

Which clinical findings are consistent with the diagnosis of acute pyelonephritis? A. Hypertension and costovertebral angle tenderness B. Increased blood urea nitrogen and fatigue C. Decreased serum creatinine and chills D. Leukocytosis and flank pain

D. Leukocytosis and flank pain The clinical manifestations of acute pyelonephritis vary from mild fatigue to the sudden onset of chills, fever, vomiting, malaise, flank pain, and the lower urinary tract symptoms characteristic of cystitis, including dysuria, urinary urgency, and frequency. Costovertebral tenderness (costovertebral angle [CVA] pain) typically occurs on the affected side. A complete blood cell count shows leukocytosis and a shift to the left, with an increase in the number of immature neutrophils (bands).

An adolescent was diagnosed with CF as an infant. At this time the adolescent will need additional teaching r/t: A. Obtaining a sweat chloride test B. The effect of pancreatic enzyme on the sex hormones. C. Weight reduction diet D. Reproductive ability

D. Reproductive ability

A symptom often seen in acute glomerulonephritis is edema. The most common site the edema is first noted is in which area of the body? a) Sacrum b) Eyes c) Hands d) Ankles

Eyes Correct Explanation: Periorbital edema may accompany or precede hematuria in children with acute glomerulonephritis. Edema in the ankles, hands and sacrum are not noted in acute glomerulonephritis.

In teaching a patient with pyelonephritis about the disorder, you inform him that the organisms that cause pyelonephritis most commonly reach the kidneys through A. the bloodstream. B. the lymphatic system. C. an descending infection. D. an ascending infection.

D. an ascending infection. The organisms that usually cause urinary tract infections (UTIs) are introduced by the ascending route from the urethra and originate in the perineum.

The nurse assesses a neonate immediately after birth. Clinical sign-symptom of tracheoesophageal fistula is A. jaundice. B. bile-stained vomitus. C. absence of sucking. D. excessive amount of frothy saliva in the mouth.

D. excessive amount of frothy saliva in the mouth. Excessive salivation and drooling are indicative of tracheoesophageal fistulas. With a fistula, the child has difficulty managing the secretions, which may cause choking, coughing, and cyanosis.Jaundice is not usually associated with a tracheoesophageal fistula.Bile-stained vomitus is not usually associated with a tracheoesophageal fistula.The infant is able to suck with a tracheoesophageal fistula but is not able to manage the secretions.

Umbilical hernia Defect location? Associated with? Tx?

Defect in midline Associated with: congenital hypothyroidism (also big tongue) Tx: repair not needed unless persists past age 2-3 years

The respiratory rate is 38 breaths/minute.

Following an intravenous pyelogram (IVP), all of the following assessment data are obtained. Which one requires immediate action by the nurse?

Assist the patient to take a 15-minute sitz bath.

Following an open loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented first?

Use an ultrasound scanner to check the postvoiding residual.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which nursing action is most appropriate?

The child with nephrotic syndrome who has ascites and difficulty breathing is probably most comfortable sleeping in which position? a) Supine b) Sims' position c) Prone d) Fowler's

Fowler's Correct Explanation: A Fowler's position (sitting upright) allows ascites fluid to settle downward and not press against the diaphragm, compromising breathing.

The nurse is assessing a male neonate and notes that the urethral opening is on the ventral aspect of the penis. The nurse documents this finding as which of the following? a) Bladder exstrophy b) Patent urachus c) Epispadias d) Hypospadias

Hypospadias Correct Explanation: Hypospadias is a condition in which the urethral opening in on the ventral surface of the penis. Epispadias is present when the urethral opening is on the dorsal surface of the penis. Patent urachus refers to a fistula between the bladder and umbilicus. Bladder exstrophy involves the bladder lying open and exposed on the abdomen.

inflammatory reaction in the glomerulus most commonly as a result of an antigen-antibody response to beta hemolytic streptocci

Glomerulonephritis

A nurse is performing an assessment on a child. Which of the following would be indicative of a potential for a urinary tract infection? a) Holding urine while at school. b) Not using cleansing towelettes routinely. c) Washing the genital area with water daily. d) Not using soap when cleaning the urethral area.

Holding urine while at school. Correct Explanation: UTIs are often caused by children who do not urinate frequently at school. It is important for a child to avoid using towelettes and soap in the genital area because this can increase the chance of a UTI. Washing the genital area with water daily does not increase the chance of a UTI.

A (The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner's syndrome, have a higher incidence of CHD. PTS: 1 DIF: Cognitive Level: Application REF: 1321 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance)

In which situation is there the greatest risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner's syndrome

D (Preoperative teaching should always be directed at the child's stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group does not understand in-depth descriptions. Preschoolers should be prepared close to the time of the cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance)

José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: a. Directed at his parents because he is too young to understand. b. Detailed in regard to the actual procedures so he will know what to expect. c. Done several days before the procedure so that he will be prepared. d. Adapted to his level of development so that he can understand.

The nurse is caring for an 8-year-old hospitalized child with nephrotic syndrome. Which of the following nursing interventions would be appropriate for this child? a) Test the urine for ketones twice a day b) Weigh the child once a week. c) Administer antipyretics as needed. d) Measure the abdominal girth daily.

Measure the abdominal girth daily. Correct Explanation: Measure the child's abdomen daily at the level of the um bilicus, and make certain that all staff personnel measure at the same level. Weigh the child at the same time every day on the same scale in the same clothing. Test the urine regularly for albumin and specific gravity. Elevated temperature is not an issue with nephrotic syndrome.

Congenital adrenal hyperplasia S/S? Most common cause? Dx test? Tx?

Newborn child with ambiguous genitalia At 1 month: vomiting, decreased Na+, increased K+, acidosis MCC: 21-hydroxylase deficiency (autosomal recessive) Definitive test: 17-OH progesterone before & after ACTH bolus Tx: hydrocortisone & fludrocortisone (increase dose in times of stress)

cyptorchidism S/S? Common location? Next best test? Tx?

Newborn male with no palpable testes Usually located: inguinal canal Next best test: ultrasound Tx: surgery —> if not descended by 1st year to avoid sterility & cancer

Pyloric stenosis S/S? Complication? Tx?

Non-bilious vomiting & palpable olive Metabolic complications: hypochloremic metabolic alkalosis Tx: immediate surgery referral for myotomy

C, F (The extremity that was used for access for the cardiac catheterization must be checked for temperature and color. Coolness and blanching may indicate arterial occlusion. The child should have a patent peripheral intravenous line to ensure adequate hydration. Allowing ambulation, monitoring vital signs every 2 hours, checking pulses, and removing the pressure dressing after 4 hours are interventions that do not apply to a child after a cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

Nursing interventions for the child after a cardiac catheterization include which of the following (Select all that apply)? a. Allow ambulation as tolerated. b. Monitor vital signs every 2 hours. c. Assess the affected extremity for temperature and color. d. Check pulses above the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Maintain a patent peripheral intravenous catheter until discharge.

A (The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace and regulate their activities. The child will limit activities as necessary. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. PTS: 1 DIF: Cognitive Level: Analysis REF: 1339 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity)

Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on knowing that: a. The child needs opportunities to play with peers. b. The child needs to understand that peers' activities are too strenuous. c. Parents can meet all the child's needs. d. Constant parental supervision is needed to avoid overexertion.

utilization of the peritoneal cavity and peritoneum as the semipermeable membrane that removes excess fluid

Peritoneal dialysis

The nurse is collecting data on a 6-year-old child admitted with a possible urinary tract infection. Which of the following vital signs might indicate the possibility of an infection? a) Respirations 22 per minute b) Blood Pressure 100/70 c) Pulse rate 135 bpm d) Pulse oximetry 93% on room air

Pulse rate 135 bpm Correct Explanation: Data to collect regarding the child includes temperature, pulse (be alert for tachycardia) and respiration rates; normal vital signs for a 6-year-old would be a pulse rate of 70 to 115 beats per minute, so this rate shows tachycardia,. The other vital signs are all within normal limits for this age child.

The nurse is teaching a group of nursing students about genitourinary conditions. The nurse tells these students about a condition that occurs when there is an inflammation of the kidney and renal pelvis. The condition the nurse is referring to is which of the following? a) Ascites b) Oliguria c) Pyelonephritis d) Amenorrhea

Pyelonephritis Correct Explanation: Pyelonephritis is an inflammation of the kidney and renal pelvis. Oliguria is a subnormal volume of urine. Amenorrhea is the absence of menstruation. Ascites is edema in the peritoneal cavity.

GFR increases during this phase of ARF

Recovery

The nurse is caring for a child admitted with acute glomerulonephritis. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) Smoky colored urine b) Jaundiced skin c) Strawberry red tongue d) Loose, dark stools

Smoky colored urine Explanation: The presenting symptom in acute glomerulonephritis is grossly bloody urine. The caregiver may describe the urine as smoky or bloody. Periorbital edema may accompany or precede hematuria. Loose stools are seen in diarrhea. A strawberry colored tongue is a symptom seen in the child with Kawasaki disease. Jaundiced skin is noted in Hepatitis.

D (The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs. PTS: 1 DIF: Cognitive Level: Analysis REF: 1323 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation)

Surgical closure of the ductus arteriosus would: a. Stop the loss of unoxygenated blood to the systemic circulation. b. Decrease the edema in legs and feet. c. Increase the oxygenation of blood. d. Prevent the return of oxygenated blood to the lungs.

The caregiver of a child being treated at home for acute glomerulonephritis calls the nurse reporting that her daughter has just had a convulsion. The child is resting comfortably but the caregiver would like to know what to do. The nurse would instruct the caregiver to do which of the following actions? a) Give the child fluids and report back to the nurse in a few hours. b) Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone. c) Give the child a diuretic and report back to the nurse in a few hours. d) Weigh the child in the same clothes she had been weighed in the day before and report the two weighs to the nurse while the nurse is on the phone.

Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone. Correct Explanation: Blood pressure should be monitored regularly using the same arm and a properly fitting cuff. If hypertension develops, a diuretic may help reduce the blood pressure to normal levels. An antihypertensive drug may be added if the diastolic pressure is 90 mm Hg or higher. The concern is immediate so reporting the findings in a few hours could delay needed treatment. The child should be weighed daily in the same clothes and using the same scale, but the blood pressure is the priority in this situation.

"I will empty my bladder every 3 to 4 hours during the day."

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) for a patient with cystitis has been effective when the patient states, ___________________

A (The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment. PTS: 1 DIF: Cognitive Level: Application REF: 1345 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement? a. Administering penicillin b. Avoiding salicylates (aspirin) c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops

A (Because a catheter is introduced into the heart, a risk exists of catheter-induced arrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, congestive heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

The nurse is assessing a child post-cardiac catheterization. Which complication might the nurse anticipate? a. Cardiac arrhythmia b. Hypostatic pneumonia c. Congestive heart failure d. Rapidly increasing blood pressure

D (If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician and applying a new bandage with more pressure can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. The Trendelenburg position would not be helpful; it would increase the drainage from the lower extremities. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: a. Notify the physician. b. Apply a new bandage with more pressure. c. Place the child in the Trendelenburg position. d. Apply direct pressure above the catheterization site.

C, D, E (The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.)

The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include (Select all that apply)? a. Warm flushed extremities b. Weight loss c. Decreased urinary output d. Sweating (inappropriate) e. Fatigue

B (Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1335 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is evaluating a child who is taking digoxin for her cardiac condition. The nurse is cognizant that a common sign of digoxin toxicity is: a. Seizures. b. Vomiting. c. Bradypnea. d. Tachycardia.

C (It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Administration of a glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrates to spare body protein and avoid ketosis.)

The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. The nurse should include: a. Avoiding carbohydrate-containing liquids. b. Giving nothing by mouth for 24 hours. c. Brushing teeth or rinsing mouth after vomiting. d. Giving plain water until vomiting ceases for at least 24 hours.

B (The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching? a. "I should avoid tub baths but may shower." b. "I have to stay on strict bed rest for 3 days." c. "I should remove the pressure dressing the day after the procedure." d. "I may attend school but should avoid exercise for several days."

A (The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation)

The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct? a. "You may need to increase the caloric density of your infant's formula." b. "You should feed your baby every 2 hours." c. "You may need to increase the amount of formula your infant eats with each feeding." d. "You should place a nasal oxygen cannula on your infant during and after each feeding."

Disconnecting the catheter from the drainage tube to obtain a specimen

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene?

identify renal artery or aortic bruits.

The nurse uses auscultation during assessment of the urinary system to __________________

D (Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Very small amounts of the liquid are given to infants, which makes it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation they should be prepared to administer the drug safely. PTS: 1 DIF: Cognitive Level: Analysis REF: 1351 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

The parents of a young child with congestive heart failure tell the nurse that they are "nervous" about giving digoxin. The nurse's response should be based on knowing that: a. It is a safe, frequently used drug. b. It is difficult to either overmedicate or undermedicate with digoxin. c. Parents lack the expertise necessary to administer digoxin. d. Parents must learn specific, important guidelines for administration of digoxin.

D (Most children with Hirschsprung's disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprung's disease is usually temporary.)

Therapeutic management of most children with Hirschsprung's disease is primarily: a. Daily enemas. b. Low-fiber diet. c. Permanent colostomy. d. Surgical removal of affected section of bowel.

C (ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended and neither are antidiarrheals because they do not get rid of pathogens.)

Therapeutic management of the child with acute diarrhea and dehydration usually begins with: a. Clear liquids. b. Adsorbents such as kaolin and pectin. c. Oral rehydration solution (ORS). d. Antidiarrheal medications such as paregoric.

The patient's central venous pressure (CVP) is decreased.

Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider?

D (The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. PTS: 1 DIF: Cognitive Level: Application REF: 1324 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities

C (The definition of congestive heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the metabolic demands of the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1331 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

What is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? a. Pulmonary congestion b. Congenital heart defect c. Congestive heart failure d. Systemic venous congestion

A (The chronic inflammatory process of Crohn's disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckel's diverticulum, and irritable bowel syndrome do not affect the entire GI tract.)

What is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn's disease b. Meckel's diverticulum c. Ulcerative colitis d. Irritable bowel syndrome

B (These are signs of early congestive heart failure, and the physician should be notified. Although rechecking blood pressure may be indicated, it is not the priority action. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms; however, medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the physician is the priority nursing action. PTS: 1 DIF: Cognitive Level: Analysis REF: 1331 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. b. Alert the physician. c. Withhold oral feeding. d. Increase the oxygen rate.

D (Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.)

What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers

recent sore throat and fever.

When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about ________________

gonococcal urethritis.

When assessing a 30-year-old man who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of ______________

pain with urination.

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about _____________

C (Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).)

When caring for a child with probable appendicitis, the nurse should be alert to recognize that a sign of perforation is: a. Bradycardia. b. Anorexia. c. Sudden relief from pain. d. Decreased abdominal distention.

monitoring and recording blood pressure.

When planning teaching for a patient with benign nephrosclerosis the nurse should include instructions regarding ________________

B (The child and family should be exposed to the sights and sounds of the intensive care unit. All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment, and its use should be demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, and endotracheal tube. PTS: 1 DIF: Cognitive Level: Analysis REF: 1341 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance)

When preparing a school-age child and the family for heart surgery, the nurse should consider: a. Not showing unfamiliar equipment. b. Letting child hear the sounds of an electrocardiograph monitor. c. Avoiding mentioning postoperative discomfort and interventions. d. Explaining that an endotracheal tube will not be needed if the surgery goes well.

"Do you have any pain when you urinate?"

When reading a patient's chart, the nurse notes that the patient has dysuria. To assess whether there is any improvement, which question will the nurse ask?

Heart rate 102 beats/minute

Which assessment finding for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the physician?

Blood pressure 88/45 mm Hg

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

B (Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common in septic shock. Angioneurotic edema occurs as a manifestation in anaphylactic shock. PTS: 1 DIF: Cognitive Level: Analysis REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

Which clinical changes occur as a result of septic shock? a. Hypothermia b. Increased cardiac output c. Vasoconstriction d. Angioneurotic edema

D (Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurney's point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.)

Which clinical manifestation would most suggest acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney's point

C, D, F (Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. PTS: 1 DIF: Cognitive Level: Analysis REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

Which clinical manifestations would the nurse expect to see as shock progresses in a child and becomes decompensated shock (Select all that apply)? a. Thirst and diminished urinary output b. Irritability and apprehension c. Cool extremities and decreased skin turgor d. Confusion and somnolence e. Normal blood pressure and narrowing pulse pressure f. Tachypnea and poor capillary refill time

There is a nontender lump in the axilla.

Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse?

Peripheral and periorbital edema is resolved.

Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective?

Urine output over an 8-hour period is 2500 mL.

Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider?

Left-sided flank pain

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider?

Calculated glomerular filtration rate (GFR)

Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)?

The urine may turn a reddish-orange color.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)?

D (Offering realistic choices is helpful in meeting the school-age child's sense of control. To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. Decreasing the amount of sugar in the diet will help keep stools soft. Daily Fleet enemas can result in hypernatremia and hyperphosphatemia, and are used only during periods of fecal impaction.)

Which intervention should be included in the nurse's plan of care for a 7-year-old child with encopresis who has cleared the initial impaction? a. Have the child sit on the toilet for 30 minutes when he gets up in the morning and at bedtime. b. Increase sugar in the child's diet to promote bowel elimination. c. Use a Fleet enema daily. d. Give the child a choice of beverage to mix with a laxative.

Check blood pressure before starting dialysis.

Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician?

Change the ostomy appliance.

Which nursing action should the nurse who is caring for a patient who has had an ileal conduit for several years delegate to nursing assistive personnel (NAP)?

Avoid unnecessary catheterizations.

Which nursing action will be most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital?

Ask about the usual urinary pattern and any measures used for bladder control.

Which of the following actions will the nurse plan to take first when admitting a patient who has a history of neurogenic bladder as a result of a spinal cord injury?

Hemoglobin level 13 g/dL

Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)?

A (Osler's nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings located over bony prominences, commonly found in rheumatic fever. Aschoff's nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1344 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? a. Osler's nodes b. Janeway lesions c. Subcutaneous nodules d. Aschoff's nodules

Urine output

Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation?

Phosphate level

Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

C (Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid acute onset. The incubation period is approximately 3 weeks for hepatitis A. The principal mode of transmission for hepatitis A is the fecal-oral route. Hepatitis A does not have a carrier state.)

Which statement best characterizes hepatitis A? a. The incubation period is 6 weeks to 6 months. b. The principal mode of transmission is through the parenteral route. c. Onset is usually rapid and acute. d. There is a persistent carrier state.

"I will measure my urinary output each day to help calculate the amount I can drink."

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective?

C (Blood stools are often a presenting sign of Meckel's diverticulum. It is associated with mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum.)

Which statement is most descriptive of Meckel's diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

B, C, D, E (The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother's nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B can exist in a carrier state.)

Which statements regarding hepatitis B are correct (Select all that apply)? a. Hepatitis B cannot exist in a carrier state. b. Hepatitis B can be prevented by hepatitis B virus vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. The onset of hepatitis B is insidious. e. Immunity to hepatitis B occurs after one attack.

A (Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not aortic stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an atrial septal defect, and overriding aorta, not aortic hypertrophy, is present. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1327 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

Which structural defects constitute tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

D (Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.)

Which type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Hypotonic dehydration c. Isosmotic dehydration d. Hypertonic dehydration

D (A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.)

Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Omphalocele c. Incarcerated hernia d. Strangulated hernia

The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition? a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema

a. Oliguria and hypertension The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure.

The classic clinical triad of intussusception is intermittent, severe, crampy ____ ____; a palpable sausage-shaped mass on the right side of the _____; and currant ____ ____.

abdominal pain, abdome, jelly stools

Status Asthmatics

acute exacerbation of asthma, unresponsive to reduce medications-> MEDICAL EMERGENCY -position them ups right, give them o2, cardiopulmonary monitoring, continuous nebulizers, establish IV access, IV meds/fluids (corticosteroids, magnesium, theophylline, normal saline), monitor electrolytes (esp K+ and Mg++)

Which is an objective of care for a 10-year-old child with minimal change nephrotic syndrome? a. Reduce blood pressure. b. Reduce excretion of urinary protein. c. Increase excretion of urinary protein. d. Increase ability of tissues to retain fluid.

b. Reduce excretion of urinary protein. The objectives of therapy for the child with minimal change nephrotic syndrome include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimization of complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and fluid retention are part of the disease process and must be reversed.

Which is included in the diet of a child with minimal change nephrotic syndrome? a. High protein b. Salt restriction c. Low fat d. High carbohydrate

b. Salt restriction Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals.

A child is admitted with acute glomerulonephritis. The nurse should expect the urinalysis during this acute phase to show: a. bacteriuria, hematuria. b. hematuria, proteinuria. c. bacteriuria, increased specific gravity. d. proteinuria, decreased specific gravity.

b. hematuria, proteinuria Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase.

Which is a common side effect of short-term corticosteroid therapy? a. Fever b. Hypertension c. Weight loss d. Increased appetite

d. Increased appetite Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy.

* what might occur if dialysate is left in the peritoneal cavity too long?

hyperglycemia

Streptococcal Pharyngitis

oAbrupt onset oSevere sore throat oPainful cervical nodes oFever greater than 101° oTonsillar exudate oAnorexia, nausea, vomiting oAbdominal pain (hallmark sign of streptococcal pharyngitis in school-age child) oHeadache, malaise oPossible scarlatina rash

Viral Pharyngitis

oMild sore throat oConjunctivitis oCough oHoarseness/ abnormal voice changes oMild throat redness oFever below 101°

Respiratory failure

-slow or absent rate, weak or no effort, decrease o2 stats, child is very quirt, failing to compensate (decompensation) -bradypnea, periodic apnea, falling heart rate/bradycardia, poor to absent air movement, low oxygen saturation, stupor, coma, unresponsiveness, poor muscle tone, cyanosis -At this late point, the child is about to go into complete cardiopulmonary arrest

Bronchiolitis/ Respiratory Syncytial Virus (RSV): Manifestations

-tachypnea -thick nasal discharge -respiratory distress: grunting, wheezing, crackles, retractions, nasal flaring -irritability and lethargy -air trapping and atelectasis -distended abdomen -poor fluid/food intake -severe coughing -vomiting

Tonsillitis & Adenoiditis

-tonsils and adenoids are important parts of the body's defense against infection -enlarged tonsils and adenoids can cause mouth breathing, obstructive sleep apnea, and ear infections -happens most often in preschool to mid-teenage years -caused by a virus or bacterium- groups A beta-hemolytic streptococcal infection- particularly dangerous

The nurse is caring for a client in the cardiac care unit with heart disease. The nurse knows that the direction of blood flows through the heart and lungs in which order? Please arrange the blood flow in the direction of flow. All options must be used Blood flows to the right atrium from the superior and inferior vena cavae. Blood flows from the right atrium to the right ventricle via the tricuspid valve. Blood flows from the right ventricle to the lungs for oxygenation. Blood flows from the lungs to the left atrium. Blood flows from the left atrium via the mitral valve to the left ventricle. Blood flows from the left ventricle to the aorta and then to the systemic circulation.

1 Blood flows to the right atrium from the superior and inferior vena cavae. 2 Blood flows from the right atrium to the right ventricle via the tricuspid valve. 3 Blood flows from the right ventricle to the lungs for oxygenation. 4 Blood flows from the lungs to the left atrium. 5 Blood flows from the left atrium via the mitral valve to the left ventricle. 6 Blood flows from the left ventricle to the aorta and then to the systemic circulation. Rationale: Nurses need to be aware of how the blood flows through the heart in order to know how any alterations in this pathway can affect the many functions of the heart. Blood returns to the heart via the superior and inferior vena cavae and then progresses through the right atrium to the lungs for oxygenation and then returns and progresses to the left side of the heart and then out through the aorta to the systemic circulation.

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? 1. Administer another nitroglycerin tablet. 2. Apply 1 to 3 L/minute of oxygen via nasal cannula. 3. Call for a 12-lead electrocardiogram (ECG) to be performed. 4. Wait an additional 5 minutes, then give a second nitroglycerin tablet.

1. Administer another nitroglycerin tablet. Rationale: In the hospitalized client, nitroglycerin tablets usually are prescribed 1 every 5 minutes as needed (PRN) for chest pain up to a total dose of 3 tablets. The nurse in this question should administer the second tablet. The client with known angina pectoris should have low-flow oxygen at a rate of 1 to 3 L/minute via nasal cannula, if pain is not relieved. A 12-lead ECG would be done if prescribed by standing protocol or by individual health care provider prescription.

The client is in with complaints of burning with urination. The MD orders a urine sample. Which technique will you use to collect the correct type of sample? 1. Clean-catch 2. Random 3. 24 hour sample 4. Creatinine clearance

1. Clean-catch

Which is the nurse's best response to the parent of a child diagnosed with epiglottitis who asks what the treatment will be? 1. Complete a course of intravenous antibiotics. 2. Surgery to remove the tonsils. 3. 10 days of aerosolized ribavirin. 4. No intervention.

1. Complete a course of intravenous antibiotics. Epiglottitis is bacterial in nature and requires intravenous antibiotics. A 7- to 10-day course of oral antibiotics is usually ordered following the intravenous course of antibiotics.

Mr. O has been on antibiotics for a sinus infection and now complains of 4 - 5 watery stools every day. What is his nursing diagnosis> 1. Diarrhea 2. Constipation 3. Bowel Incontinence 4. Normal bowel activity

1. Diarrhea

The client states "I am gluten free because I felt terrible when I was eating gluten" You would expect that this client would refuse to eat: 1. Grain products 2. Dairy products 3. Meat products 4. Coffee

1. Grain products

The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? 1. Pedal edema that is 3+ 2. Slight residual calf tenderness 3. Skin warm, equal temperature both legs 4. Calf girth ⅛ inch larger than unaffected limb

1. Pedal edema that is 3+ Rationale: Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain. Option 3 indicates full resolution of the problem, whereas options 2 and 4 indicate partial resolution. Option 1 is the correct option because it indicates the least degree of symptom reversal.

The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? 1. Shock 2. Kidney dysfunction 3. Respiratory insufficiency 4. Increased intracranial pressure

1. Shock Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock. The remaining conditions would not benefit from and, in some cases, would worsen because of this position.

How to use a spray inhaler

1. Take off the cap. Shake the inhaler 2. Stand up. Breath out (exhale) 3. Pit the inhaler in your mouth or put it just in from of your mouth. As you start to breathe in, push down on the top of the inhaler and keep breathing in slowly 4. Hold your breath for 10 seconds. Breath out

The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason? 1. The client requires prophylactic antibiotics before treatment. 2. The dentist should use a low-speed drill to avoid dysrhythmias. 3. The dentist should use a lidocaine solution without epinephrine. 4. The client is at risk for episodes of heart failure triggered by stressful events.

1. The client requires prophylactic antibiotics before treatment. Rationale: The client with a history of rheumatic fever is at risk for developing infective endocarditis. The client should tell all health care providers and dentists about this problem so that prophylactic antibiotic therapy can be given before any procedure that is invasive or carries a risk of bleeding. Options 2, 3, and 4 are unrelated to rheumatic heart disease.

14. The nurse is caring for an infant newly diagnosed with Hirschsprung disease. Which of the following does the nurse understand about this infant's condition? 1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 2. There is excessive peristalsis throughout the intestine, resulting in abdominal distention. 3. There is a small-bowel obstruction leading to ribbon-like stools. 4. There is inflammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention.

1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention.

Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin? 1. To prevent the formation of clots 2. To relieve pain at the injection site 3. To prevent a fever after the procedure 4. To prevent inflammation of the injection site

1. To prevent the formation of clots Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure. Options 2, 3, and 4 are unrelated to the purpose of administering aspirin to this client.

A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. 1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry. 5. Select whole milk products.

1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry. Rationale: Hyperlipidemia is a modifiable risk factor for the development of coronary heart disease. Reducing the amount of dietary saturated fat and cholesterol helps lower the risk for coronary heart disease. Dietary modifications such as the using liquid vegetable oil, eating fresh fruits and whole grain foods, and removing the skin from poultry will lower dietary fat. The client should also use low-fat or fat-free (skim) milk in place of whole milk products to lower dietary fat.

Which position would be most comfortable for a child with left-sided pneumonia? 1. Trendelenburg. 2. Left side. 3. Right side. 4. Supine.

2. Left side. Lying on the left side may provide the patient with the most comfort. Lying on the left splints the chest and reduces the pleural rubbing.

The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health? 1. Knowledge of when it is safe to resume sexual activity 2. The ability to take an accurate pulse in either the wrist or neck 3. An understanding of the importance of proper microwave oven usage 4. An understanding of why vigorous arm and shoulder movement must be avoided initially

2. The ability to take an accurate pulse in either the wrist or neck Rationale: Clients with permanent pacemakers must be able to accurately take their pulse in the wrist and/or neck. The client needs to identify any variation in the pulse rate or rhythm and immediately report the variation to the health care provider. Clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars (proper grounding must be ensured if the client is to operate electrical items). Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. The remaining options do not have the same impact on long-term cardiac health as does the correct option.

A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? 1. Bed rest 2. Restricting fluids 3. Antihypertensives 4. Maintaining a low-fiber diet

3. Antihypertensives Rationale: The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low-fiber diet is not helpful and will cause constipation.

An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem? 1. "Can you describe the pain to me?" 2. "Have you ever had this pain before?" 3. "Does the pain get worse when you breathe in?" 4. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

3. "Does the pain get worse when you breathe in?" Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Describing the pain, asking if it has occurred in the past, and rating the pain using a pain scale may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

Which is diagnostic for epiglottitis? 1. Blood test. 2. Throat swab. 3. Lateral neck x-ray of the soft tissue. 4. Signs and symptoms.

3. Lateral neck x-ray of the soft tissue. A lateral neck x-ray is a definitive test to diagnose epiglottitis. The child is at risk for complete airway obstruction and should always be accompanied by a nurse to the x-ray department.

What information should the nurse provide the parent of a child diagnosed with nasopharyngitis? 1. Complete the entire prescription of antibiotics. 2. Avoid sending the child to day care. 3. Use comfort measures for the child. 4. Restrict the child to clear liquids for 24 hours.

3. Use comfort measures for the child. Nursing care for nasopharyngitis is primarily supportive. Keeping the child comfortable during the course of the illness is all the parents can do. Nasal congestion can be relieved using normal saline drops and bulb suction. Tylenol can also be given for discomfort or a mild fever.

Recent weight gain

A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness?

Ask the patient about use of any medications.

A patient with a possible urinary tract infection (UTI) gives the nurse in the clinic a urine specimen that is a red-orange color. Which action should the nurse take first?

Administer prescribed analgesics.

A patient with renal calculi is hospitalized with gross hematuria and severe colicky left flank pain. Which nursing action will be of highest priority at this time?

maintaining cardiac output.

A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of __________________

Ibuprofen (Advil) 400 mg PO PRN for pain

A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question?

A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.) a. Weight loss b. Facial edema c. Cloudy smoky brown-colored urine d. Fatigue e. Frothy-appearing urine

ANS: B, D, E A child with nephrotic syndrome will present with facial edema, fatigue, and frothy-appearing urine (proteinuria). Weight gain, not loss, is expected because of the fluid retention. Cloudy smoky brown-colored urine is seen with acute glomerulonephritis but not with nephrotic syndrome because there is no gross hematuria associated with nephrotic syndrome.

C (If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are to be avoided by using the appropriate technique. PTS: 1 DIF: Cognitive Level: Application REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity)

An important nursing consideration when suctioning a young child who has had heart surgery is to: a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Administer supplemental oxygen before and after suctioning. d. Expect symptoms of respiratory distress when suctioning.

You identify a risk factor for kidney and bladder cancer in a patient who relates a history of A. aspirin use. B. tobacco use. C. chronic alcohol abuse. D. use of artificial sweeteners.

B. tobacco use. Cigarette smoking is the most significant risk factor for renal cell carcinoma. An increased incidence also has been seen among first-degree relatives. Other risk factors include obesity, hypertension, and exposure to asbestos, cadmium, and gasoline. The risk of renal cancer is increased for individuals who have acquired cystic disease of the kidney associated with end-stage renal disease. Risk factors for bladder cancer include smoking, exposure to dyes used in the rubber and cable industries, and chronic abuse of phenacetin-containing analgesics.

C (The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.)

During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine.

You identify a risk for urinary calculi in a patient who relates a health history that includes A. adrenal insufficiency. B. serotonin deficiency. C. hyperaldosteronism. D. hyperparathyroidism.

D. hyperparathyroidism. Excessive levels of circulating parathyroid hormone (PTH) usually lead to hypercalcemia and hypophosphatemia. In the kidneys excess calcium in the filtrate cannot be reabsorbed, leading to increased levels of calcium in the urine (hypercalciuria). This increased urinary calcium level along with a large amount of urinary phosphate can lead to calculi formation.

When developing an expected outcome for the patient with urinary retention, you would include A. freedom from bladder fullness. B. patient who verbalizes need to void. C. fluid intake less than 1200 mL/day. D. non-palpable bladder after voiding.

D. non-palpable bladder after voiding. If the bladder is emptied fully, you should not be able to palpate it.

Gastroschisis Defect location? Maternal finding? Complications?

Defect lateral to midline and no sac (omphalocele has sac) High maternal AFP Associated disorders: not usually Complications: may have atretic or necrotic bowel requiring removal = short gut syndrome

A nurse is developing a teaching plan for the parents of an 8 year old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents identify which of the following as an appropriate measure? a) Engaging the child in stress reduction measures b) Giving desmopressin intranasally c) Encouraging fluid intake after dinner d) Practicing bladder-stretching exercises

Encouraging fluid intake after dinner Correct Explanation: In many children, limiting fluids after dinner can be helpful for nocturnal enuresis. Bladder-stretching exercises also can be helpful. If these measures are ineffective, desmopressin may be prescribed. Stress factors may be contributing to the child's problem. Therefore, measures to address stress and promote coping would be appropriate.

The nurse is caring for a child with nephrotic syndrome. The child is noted to have edema. The edema would most likely be seen where on this child? a) Sacrum b) Abdomen c) Eyes d) Fingers

Eyes Correct Explanation: Edema is usually the presenting symptom in nephrotic syndrome, appearing first around the eyes and ankles.

Place the patient on bed rest.

In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care?

hypospadias S/S? What not to do?

Male with urethral opening on ventral surface DO NOT circumcise (foreskin is used for repair)

You auscultate a client's abdomen as part of a focused physical assessment for bowel elimination. You hear high-pitched sounds, with about 10 gurgles in a minute. Which of the following conditions is most associated with this type of bowel sound?

NORMAL

A child diagnosed acute glomerulonephritis will most likely have a history of which of the following? a) Recent illness such as strep throat b) Hemorrhage or history of bruising easily c) Sibling diagnosed with the same disease d) Hearing loss with impaired speech development

Recent illness such as strep throat Correct Explanation: Symptoms of acute glomerulonephritis often appear one to three weeks after the onset of a streptococcal infection such as strep throat.

A (Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.)

Nurses must be alert for increased fluid requirements when a child has: a. Fever. b. Congestive heart failure. c. Mechanical ventilation. d. Increased intracranial pressure (ICP).

D (In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or an elevated temperature continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. A hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. PTS: 1 DIF: Cognitive Level: Analysis REF: 1341 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity)

Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7 C (101 F). The nurse should: a. Keep the child warm with blankets. b. Apply a hypothermia blanket. c. Record the temperature on nurses' notes. d. Report findings to physician.

The LPN/LVN gives the iron supplement and phosphate binder with lunch.

The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene?

B (The objective of nursing care is to counsel the parents of high risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Observing for complications and encouraging restricted mobility in susceptible children should be done, but maintaining good oral health and using prophylactic antibiotics are most important.)

The primary nursing intervention necessary to prevent bacterial endocarditis is to: a. Institute measures to prevent dental procedures. b. Counsel parents of high risk children about prophylactic antibiotics. c. Observe children for complications such as embolism and heart failure. d. Encourage restricted mobility in susceptible children.

60, The creatinine clearance approximates the GFR.

The result of a patient's creatinine clearance test is 60 mL/min. The nurse equates this finding to a glomerular filtration rate (GFR) of _____ mL/min.

While caring for a client in the hospital, you observe that she has to get up several times during the night to urinate. As you investigate this, you first conduct a nursing history with the client. What is the best rationale for taking a nursing history in this case?

This urination pattern might be normal for the client.

In caring for a child with nephrotic syndrome, which of the following interventions will be included in the child's plan of care? a) Ambulating three to four times a day b) Testing the urine for glucose levels regularly c) Increasing fluid intake by 50 cc an hour d) Weighing on the same scale each day

Weighing on the same scale each day Correct Explanation: The child with nephrotic syndrome is weighed every day using the same scale to accurately monitor the child's fluid gain and loss.

WBC: 20-26/hpf

When reviewing the results of a patient's urinalysis, which information indicates that the nurse should notify the health care provider?

Document the information on the assessment form.

While assessing a patient's urinary system, the nurse cannot palpate either kidney. Which action should the nurse take next?