Nur 237 test 2

Which of the following factors need(s) to be included in a teaching plan for a child with sickle cell anemia? Select all that apply. 1. The child needs to be taken to a physician when sick. 2. The parent should make sure the child sleeps in an air-conditioned room. 3. Emotional stress should be avoided. 4. It is important to keep the child well hydrated. 5. It is important to make sure the child gets adequate nutrition.

1, 3, 4, 5. 1. Seek medical attention for illness to prevent the child from going into a crisis. 3. Stress can cause a depressed immune system, making the child more susceptible to infection and crisis. Parents and children are advised to avoid stress. 4. The child needs good hydration and nutrition to maintain good health. 5. The child needs good hydration and nutrition to maintain good health.

The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health- care provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor 4. Serum magnesium of 1.2 mg/dL and large urinary output.

1. A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low sodium level.

A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1. An order for oxytocin administration should be questioned.

The nurse is caring for a 5-year-old child with a congenital heart anomaly causing chronic cyanosis. When performing the history and physical examination, what is the nurse least likely to assess? 1. Obesity from overeating. 2. Clubbing of the nail beds. 3. Squatting during play activities. 4. Exercise intolerance.

1. Children with CHD causing chronic cyanosis are likely to demonstrate failure to thrive, not obesity. They frequently develop clubbing of the nail beds and exercise intolerance, and those with tetralogy of Fallot or pulmonary stenosis may display hypercyanotic spells (squatting).

Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Powerlessness. 4. Anticipatory grieving.

1. Medical client problems indicate the nurse and the physician must collaborate to care for the client; the client must have medications for heart failure

The nurse is caring for a child being treated for ALL. Laboratory results indicate that the child has a white blood cell count of 5000/mm3 with 5% polys and 3% bands. Which of the following analyses is most appropriate? 1. The absolute neutrophil count is 400/mm3, and the child is neutropenic. 2. The absolute neutrophil count is 800/mm3, and the child is neutropenic. 3. The absolute neutrophil count is 4000/mm3, and the child is not neutropenic 4. The absolute neutrophil count is 5800/mm3, and the child is not neutropenic.

1. The calculated absolute neutrophil count is 400/mm3 (0.08 × 5000) and is neutropenic as it is less than 500/mm3.

Which patient could require feeding by gavage? 1. Infant with congestive heart failure (CHF). 2. Toddler with repair of transposition of the great vessels. 3. Toddler with Kawasaki disease (KD) in the acute phase. 4. School-age child with rheumatic fever (RF) and chorea.

1. The child may experience increased cardiac demand while feeding. Feedings by gavage eliminate that work and still provide high-calorie intake for growth.

3. The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.

1. ensure the client eats the bedtime snack

Which of the following is a (are) reason(s) to do a lumbar puncture on a child with a diagnosis of leukemia? Select all that apply. 1. Rule out meningitis. 2. Assess the central nervous system for infiltration. 3. Give intrathecal chemotherapy. 4. Determine increased intracranial pressure. 5. Stage the leukemia.

2, 3. 2. A lumbar puncture is done to assess the central nervous system by obtaining a specimen that can determine them presence of leukemic cells. 3. Chemotherapy can also be given witha spinal tap.

The nurse is caring for a 10-year-old with leukemia who is receiving chemotherapy. The child is on neutropenic precautions. Friends of the child come to the desk and ask for a vase for flowers. Which of the following is the best response? 1. "I will get you a special vase that we use on this unit." 2. "The flowers from your garden are beautiful but should not be placed in the room at this time." 3. "As soon as I can wash a vase, I will put the flowers in it and bring it to the room." 4. "Get rid of the flowers immediately. You could harm the child."

2. A neutropenic client should not have flowers in the room because the flowers may harbor Aspergillus or Pseudomonas aeruginosa. Neutropenic children are susceptible to infection. Precautions need to be taken so the child does not come in contact with any potential sources of infection. Fresh fruits and vegetables can also harbor molds and should be avoided. Telling the friend that the flowers are beautiful but that the child cannot have them is a tactful way not to offend the friend.

Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)? 1. Shortness of breath. 2. Abdominal bruit. 3. Ripping abdominal pain. 4. Decreased urinary output.

2. A systolic bruit over the abdomen is a diagnostic indication of an AAA.

Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure? 1. Pheochromocytoma. 2. Diabetes insipidus. 3. Hashimoto's disease. 4. Gynecomastia.

2. Diabetes insipidus can be caused by brain tumors or infections, pituitary surgery, cerebrovascular accidents, or renal and organ failure, or it may be a complication of a closed head injury with increased intra- cranial pressure. Diabetes insipidus is a result of antidiuretic hormone (ADH) insufficiency.

Which health-care provider's order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning? 1. Type and crossmatch for two (2) units of blood. 2. Tap water enema until clear fecal return. 3. Bedrest with bathroom privileges. 4. Keep NPO after midnight

2. Increased pressure in the abdomen secondary to a tap water enema could cause the AAA to rupture

The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medi bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my health-care provider."

2. Medication taken for DI is usually every 8-12 hours, depending on the client. The client should keep the medication close at hand.

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment? 1. "I have stomach pain every time I eat a big, heavy meal." 2. "I don't have any abdominal pain or any type of problems." 3. "I have periodic episodes of constipation and then diarrhea." 4. "I belch a lot, especially when I lay down after eating."

2. Only about two-fifths of clients with AAA have symptoms; the remainder are asymptomatic

The nurse is caring for a child with sickle cell disease who is scheduled to have a splenectomy. What information should the nurse explain to the parents regarding the reason for a splenectomy? 1. To decrease potential for infection. 2. To prevent splenic sequestration. 3. To prevent sickling of red blood cells. 4. To prevent sickle cell crisis.

2. Splenic sequestration is a life-threatening situation in children with sickle cell anemia. Once a child is considered to be at high risk of splenic sequestration or has had this in the past, the spleen will be removed.

15. Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICD? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2. The client in DKA loses potassium from increased urinary output, acidosis, cata- bolic state, and vomiting. Replacement is essential for preventing cardiac dysrhyth- mias secondary to hypokalemia.

The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse? 1. The client refuses to turn from the back to the side. 2. The client's urinary output is 90 mL in six (6) hours. 3. The client wants to sit on the side of the bed. 4. The client's vital signs are T 98, P 90, R 18, and BP 130/70.

2. The client must have 30 mL of urinary output every hour. Clients who are post-AAA are at high risk for renal failure because of the anatomical location of the AAA near the renal arteries

The client diagnosed with neurogenic diabetes insipidus asks the nurse, "What is wrong with me? Why do I urinate so much?" Which statement by the nurse would be most appropriate? 1. "The islet cells in your pancreas are not functioning properly." 2. "Your pituitary gland is not secreting a necessary hormone." 3. "Your kidneys are in failure and you are overproducing urine." 4. "The thyroid gland is speeding up all your metabolism."

2. The pituitary gland secretes vasopressin, which is the antidiuretic hormone (ADH) that causes the body to conserve water, and if the pituitary is not secreting ADH, the body will produce large volumes of dilute urine.

The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and head board. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2. The side rails of eclamptic clients' beds should be padded.

A client is being admitted to the labor suite with a diagnosis of eclampsia. Which of the following actions by the nurse is appropriate at this time? 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails and head of the bed. 3. Provide the client with needed stimulation. 4. Provide the client with grief counseling.

2. This is appropriate. The side rails and the head board should be padded.

Congenital heart defects (CHDs) are classified by which of the following? Select all that apply. 1. Cyanotic defect. 2. Acyanotic defect. 3. Defects with increased pulmonary blood flow. 4. Defects with decreased pulmonary blood flow. 5. Mixed defects. 6. Obstructive defects. 7. Pansystolic murmur

3, 4, 5, 6.

The nurse is taking care of a child with sickle cell disease. The nurse is aware that which of the following problems is (are) associated with sickle cell disease? Select all that apply. 1. Polycythemia. 2. Hemarthrosis. 3. Aplastic crisis. 4. Thrombocytopenia. 5. Splenic sequestration. 6. Vaso-occlusive crisis.

3, 5, 6.

13. The client diagnosed with Type 2 diabetes is admitted to the intensive care department with hyperosmolar hyperglycemic nonketonic state coma (HHS). Which assessment data would the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3. Dry mucous membranes are a result of the hyperglycemia and occur with both HHS and DKA.

Which of the following should be done to protect the central nervous system from the invasion of malignant cells in a child newly diagnosed with leukemia? 1. Cranial and spinal radiation. 2. Intravenous steroid therapy. 3. Intrathecal chemotherapy. 4. High-dose intravenous chemotherapy.

3. Giving chemotherapy via lumbar puncture allows the drugs to get to the brain and helps prevent metastasis of the disease.

A heart transplant may be indicated for a child with severe heart failure and: 1. Patent ductus arteriosus (PDA). 2. Ventricular septal defect (VSD). 3. Hypoplastic left heart syndrome. 4. Pulmonic stenosis (PS).

3. Hypoplastic left heart syndrome is treated by the Norwood procedure, or heart transplant.

Which of the following analgesics is most effective for a child with sickle cell pain crisis? 1. Demerol. 2. Aspirin. 3. Morphine. 4. Excedrin.

3. Morphine is the drug of choice for a child with sickle cell crises. Usually the child is started on oral doses of Tylenol with codeine. When that is not sufficient to alleviate pain, stronger narcotics are prescribed such as morphine.

Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)? 1. Diabetes mellitus type 2 (DM 2). 2. Seizure activity. 3. Syndrome of inappropriate antidiuretic hormone (SIADH). 4. Cushing's disease.

3. The pituitary gland produces vasopressin, the antidiuretic hormone (ADH), and any injury that causes increased intracranial pressure will exert pressure on the pituitary gland and can cause the syndrome of inappropriate antidiuretic hormone (SIADH).

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of 3. 2. Urinary output of 30 cc/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 gm/dL.

4. A serum magnesium level of 9 gm/dL is dangerously high. The health care practitioner should be notified.

Which intervention should be implemented after a bone marrow aspiration? 1. Ask the child to remain in a supine position. 2. Place the child in an upright position for 4 hours. 3. Keep the child nothing by mouth for 6 hours. 4. Administer analgesics as needed for pain.

4. Children may experience minor discomfort after the procedure, and analgesics should be given as needed.

A child with leukemia is receiving chemotherapy and is complaining of nausea. The nurse has been giving the scheduled antiemetic. Which of the following should the nurse do when the child is nauseated? 1. Encourage low-protein foods. 2. Encourage low-caloric foods. 3. Offer the child's favorite foods. 4. Offer cool, clear liquids.

4. Cool, clear liquids are better tolerated. Milk-based products cause secretions to be thick and can cause vomiting.

While assessing a 4-month-old infant, the nurse notes that the baby experiences a hypercyanotic spell. What is the priority nursing action? 1. Provide supplemental oxygen by face mask. 2. Administer a dose of IV morphine sulfate. 3. Begin cardiopulmonary resuscitation. 4. Place the infant in a knee-to-chest position.

4. Hypercyanotic spells are a dangerous event. Placing the infant in a knee-to-chest position increases systemic vascular resistance, thereby improving pulmonary blood flow. It is the first action the nurse should take.

Prednisone is given to children who are being treated for leukemia. Why is this medication given as part of the treatment plan? 1. Enhances protein metabolism. 2. Enhances sodium excretion. 3. Increases absorption of the chemotherapy. 4. Destroys abnormal lymphocytes.

4. Prednisone is used in many of the treatment protocols for leukemia because there is abnormal lymphocyte production. Prednisone is thought to destroy abnormal lymphocytes

Which of the following statements is appropriate for the nurse to say to a patient with a complete placenta previa? 1. "During the first phase of labor you will do slow chest breathing." 2. "You should ambulate in the halls at least two times each day." 3. "The doctor will deliver you once you reach 25 weeks' gestation." 4. "Please remember to tell me if you become constipated."

4. Straining at stool can result in enough pressure to result in placental bleeding.

A 2-day-old infant was just diagnosed with aortic stenosis. What is the most likely nursing assessment finding? 1. Gallop and rales. 2. Blood pressure discrepancies in the extremities. 3. Right ventricular hypertrophy on ECG. 4. Heart murmur.

4. heart murmur; other signs: left ventricular hypertrophy and pulmonary congestion. Physical signs of exercise intolerance, chest pain and dizziness when standing for long periods. 4. Typically, children with aortic stenosis have a murmur that is best heard along the left sternal border. They do not commonly exhibit a gallop, rales, or right ventricular hypertrophy. Blood pressure and pulse discrepancies between the upper and lower extremities occur with coarctation of the aorta, not aortic stenosis.

A child with leukemia has the following a.m. laboratory results: Hgb 8.0, Hct 24.2, WBC 8,000, platelets 150,000. What is the priority nursing assessment? a. Monitor for fever. b. Assess for bruising or bleeding. c. Determine intake and output. d. Assess for pallor, fatigue, and tachycardia.

d. The Hgb and Hct indicate anemia, which results in fatigue, pallor, and tachycardia.

Which of the following can be manifestations of leukemia in a child? Select all that apply. 1. Leg pain. 2. Fever. 3. Excessive weight gain. 4. Bruising. 5. Enlarged lymph nodes.

1, 2, 4, 5. 1. The proliferation of cells in the bone marrow can cause leg pain. 2. Fever is a result of the neutropenia. 4. A decrease in platelets causes the bruising. 5. The lymph nodes are enlarged from the infiltration of leukemic cells

The nurse is caring for a child with leukemia. The nurse should be aware that children being treated for leukemia may experience which of the following complications? Select all that apply. 1. Anemia. 2. Infection. 3. Bleeding tendencies. 4. Bone deformities. 5. Polycythemia.

1, 2. 1. Anemia is caused by decreased production of red blood cells. 2. Infection risk in leukemia is secondary to the neutropenia. 3. Bleeding tendencies are from decreased platelet production. 4. There are no bone deformities with leukemia, but there is bone pain from the proliferation of cells in the bone marrow. 5. Polycythemia is an increase in red blood cells.

The client diagnosed with a pituitary tumor has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions would the nurse implement? 1. Assess for dehydration and monitor blood glucose levels. 2. Assess for nausea and vomiting and weigh daily. 3. Monitor potassium levels and encourage fluid intake. 4. Administer vasopressin IV and conduct a fluid deprivation test.

2. Early signs and symptoms are nausea and vomiting. The client has a syndrome of the inappropriate secretion of the antidiuresis (against allowing the body to urinate) hormone. In other words, the client is producing a hormone that will not allow the client to urinate.

A nurse instructs the parent of a child with sickle cell anemia about factors that might precipitate a pain crisis in the child. Which of the following factors identified by the parent as being able to cause a pain crisis indicates a need for further instruction? 1. Infection. 2. Overhydration. 3. Stress at school. 4. Cold environment.

2. Overhydration does not cause a crisis.

Which of the following best describes the action of chemotherapeutic agents used in the treatment of cancer in children? 1. Suppress the function of normal lymphocytes in the immune system. 2. Are alkylating agents and are cell-specific. 3. Cause a replication of DNA and are cell-specific. 4. Interrupt cell cycle, thereby causing cell death.

1. All chemotherapy is immunosuppressive as most childhood cancers affect the immune system.

Which assessment indicates that the parent of a 7-year-old is following the prescribed treatment for congestive heart failure (CHF)? 1. HR of 56 beats per minute. 2. Elevated red blood cell count. 3. 50th percentile height and weight for age. 4. Urine output of 0.5 cc/kg/hr.

3. The 50th percentile height and weight for age shows good growth and development, indicating good nutrition and perfusion.

The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails

3. the client has a necrotic big toe

Hypoxic spells in the infant with a congenital heart defect (CHD) can cause which of the following? Select all that apply. 1. Polycythemia. 2. Blood clots. 3. Cerebrovascular accident. 4. Developmental delays. 5. Viral pericarditis. 6. Brain damage. 7. Alkalosis.

1, 4, 5, 6, 7.

The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first? 1. Assess the client's bowel sounds. 2. Administer an IV prophylactic antibiotic. 3. Encourage the client to splint the incision. 4. Ambulate the client in the room with assistance.

1. Assessment is the first part of the nursing process and is the first intervention the nurse should implement.

Which of the following is correct regarding prognostic factors for determining survival for a child newly diagnosed with ALL? 1. The initial white blood cell count on diagnosis. 2. The race of the child. 3. The amount of time needed to initiate treatment. 4. The allergy history of the child.

1. Children with a normal or low white blood cell count who do not have non-T, non-B acute lymphoblastic leukemia, and who are CALLA-positive have a much better prognosis than those with high cell counts or other cell types

A woman with a diagnosis of ectopic pregnancy is to receive medical intervention rather than a surgical interruption. Which of the following intramuscular medications would the nurse expect to administer? 1. Decadron (desamethasone). 2. Amethopterin (methotrexate). 3. Pergonal (menotropins). 4. Prometrium (progesterone)

2. Methotrexate is the likely medication

19. The nursing assistant on the medical floor tells the primary nurse that the client diagnosed with DKA wants something else to eat for lunch. What action should the nurse implement? 1. Instruct the assistant to get the client additional food. 2. Notify the dietician about the client's request. 3. Ask the assistant to obtain a glucometer reading. 4. Tell the assistant that the client cannot have anything else.

2. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietician to talk to the client to try and adjust the meals so that the client will adhere to the diet.

An 18-year-old female client, 5′4′′ tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.

2. Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 pounds and is short

The unlicensed nursing assistant complains to the nurse that she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse do first? 1. Tell the unlicensed nursing assistant to fill the pitcher again. 2. Instruct the unlicensed nursing assistant to start measuring I & O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.

3. The first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma.

32. Which statement best explains the scientific rationale for Kussmaul's respirations in the client diagnosed with diabetic ketoacidosis (DKA)? 1. The kidneys produce excess urine and the lungs try to compensate. 2. The respirations increase the amount of carbon dioxide in the bloodstream. 3. The lungs speed up to release carbon dioxide and increase the pH. 4. The shallow and slow respirations will increase the HCO3 in the serum.

3. The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid).

20. The client diagnosed with Type 2 diabetes comes to the emergency department. The client's blood glucose is 680 mg/dL and the client is diagnosed with HHS. Which question should the nurse ask the client to determine the cause of this acute complication? 1. When is the last time you took your insulin? 2. When did you have your last meal? 3. Have you had some type of infection lately? 4. How long have you had diabetes?

3. The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.

The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse that he would like to discontinue the fluid restriction and does not care if he dies. Which action by the nurse would be an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the health-care provider and significant other. 2. Explain that it is possible that the client would seize if he drank fluid beyond the restrictions. 3. Notify the health-care provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain that the nurse could get into trouble if the client tells the health-care provider.

3. This is an example of autonomy (the client has the right to decide for himself).

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

3. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

4. Epigastric pain is associated with the liver involvement of HELLP syndrome.

While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, and decreased PO2 . The nurse suspects that the newborn has: 1. Pulmonary hypertension. 2. Patent ductus arteriosus (PDA). 3. Ventricular septal defect (VSD). 4. Bronchopulmonary dysplasia.

2. The main identifier in the stem is the machine-like murmur, which is the hallmark of a PDA.

Which statement by a parent of an infant with congestive heart failure (CHF) who is being sent home on digoxin indicates the need for further education? 1. "I will give the medication at regular 12-hour intervals." 2. "If he vomits, I will not give a make-up dose." 3. "If I miss a dose, I will not give an extra dose" 4. "I will mix the digoxin in some formula to make it taste better."

4. If the medication is mixed in his formula, and he refuses to drink the entire amount, the digoxin dose will be inadequate.

24. The client is admitted to the ICD diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

1, 2, 3, 4, 5. The nurse should always address the airway when a client is seriously ill. The client must be assessed for fluid volume deficit and then for fluid volume excess after fluid replacement is started. The electrolyte imbalance of primary concern is depletion of potassium. Ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently. The nurse must ensure that the client's fluid intake and output are equal.

A child diagnosed with leukemia is receiving allopurinol as part of the treatment plan. The parents ask why their child is receiving this medication. What information about the medication should the nurse provide? 1. Helps reduce the uric acid level caused by cell destruction. 2. Used to make the chemotherapy work better. 3. Given to reduce the nausea and vomiting associated with chemotherapy. 4. Helps decrease pain in the bone marrow.

1. Allopurinol reduces serum uric acid. When there is lysis of cells from chemotherapy, there will be an increase in serum uric acid.

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair? 1. Absent bilateral pedal pulses. 2. Complaints of pain at the site of the incision. 3. Distended, tender abdomen. 4. An elevated temperature of 100 ̊F.

1. Any neurovascular abnormality in the client's lower extremities indicates the graft is occluded or possibly bleeding and requires immediate intervention by the nurse

The nurse is caring for a child with a diagnosis of ALL who is receiving chemotherapy. The nurse notes that the child's platelet count is 20,000/mm3. Based on this laboratory finding, what information should the nurse provide to the child and parents? 1. A soft toothbrush should be used for mouth care. 2. Isolation precautions should be started immediately. 3. The child's vital signs, including blood pressure, should be monitored every 4 hours. 4. All visitors should be discouraged from coming to see the family.

1. Because the platelet count is decreased, there is a significant risk of bleeding, especially in soft tissue. The use of the soft toothbrush should help prevent bleeding of the gums.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

1. Fundal heights increase during pregnancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour.

The nurse is caring for a child with sickle cell anemia who is scheduled to have an exchange transfusion. What information should the nurse teach the family? 1. The procedure is done to prevent further sickling during a vaso-occlusive crisis. 2. The procedure reduces side effects from blood transfusions. 3. The procedure is a routine treatment for sickle cell crisis. 4. Once the child's spleen is removed, it is necessary to do exchange transfusions.

1. Exchange transfusion reduces the number of circulating sickle cells and slows down the cycle of hypoxia, thrombosis, and tissue ischemia.

A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is: 1. Feeding formula that is supplemented with additional calories. 2. Allowing the infant to nurse at each breast for 20 minutes. 3. Providing large feedings every 5 hours. 4. Using firm nipples with small openings to slow feedings.

1. Formula can be supplemented with extra calories, either from a commercial supplement, such as Polycose, or from corn syrup. Calories in formula could increase from 20 kcal/oz to 30 kcal/oz or more.

The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm. Which sign/symptom would make the nurse suspect the client has an expanding AAA? 1. Complaints of low back pain. 2. Weakened radial pulses. 3. Decreased urine output. 4. Increased abdominal girth.

1. Low back pain is present because of the pressure of the aneurysm on the lumbar nerves; this is a serious symptom, usually indicating that the aneurysm is expanding rapidly and about to rupture

A 3-year-old is hospitalized for an ASD repair. The parents have decided to go home for a few hours to spend time with her siblings. The child asks when her mommy and daddy will be back. The nurse's best response is: 1. "Your mommy and daddy will be back after your nap." 2. "Your mommy and daddy will be back at 6:00 p.m." 3. "Your mommy and daddy will be back later this evening." 4. "Your mommy and daddy will be back in 3 hours."

1. Preschoolers understand time in relation to events. The flow of blood through the heart with an atrial septal defect (ASD) is Left to right. The pressures in the left side of the heart are greater, causing the flow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood flow with the extra blood

The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client? 1. Notify HCP of any redness or irritation of the incision. 2. Do not lift anything that weighs more than 20 pounds. 3. Inform client there may be pain not relieved with pain medication. 4. Stress the importance of having daily bowel movements.

1. Redness or irritation of the incision indicates infection and should be reported immediately to the HCP

The client is diagnosed with diabetes insipidus. Which laboratory value should be monitored by the nurse? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells.

1. The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom shared with diabetes mellitus. Diabetes in- sipidus is a totally separate disease process.

The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

1. The client with a placenta accreta is high risk for a large blood loss

14. The elderly client is admitted to the intensive care department diagnosed with severe HHS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results

1. The initial fluid replacement is O.9% normal saline (an isotonic solution) intra- venously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially that of the heart.

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level.

1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin and furosemide. She is rubbing her eyes when she is looking at the lights in the room, and her HR is 70 beats per minute. The nurse expects which laboratory finding? 1. Hypokalemia. 2. Hypomagnesemia. 3. Hypocalcemia. 4. Hypophosphatemia.

1. The rubbing of the child's eyes may mean that she is seeing halos around the lights, indicating digoxin toxicity. The HR is slow for her age and also indicates digoxin toxicity. A decrease in serum potassium because of the furosemide can increase the risk for digoxin toxicity.

The nurse is caring for a 32-week G8P7007 with placenta previa. Which of the following interventions would the nurse expect to perform? Select all that apply. 1. Daily contraction stress tests. 2. Blood type and cross match. 3. Bed rest with passive range of motion exercises. 4. Daily serum electrolyte assessments. 5. Weekly biophysical profiles.

2, 3, and 5 are correct. 2. There should be blood available in the blood bank in case the woman begins to bleed. 3. The nurse would expect to keep the woman on bed rest with bathroom privileges only. 5. The nurse would expect that weekly biophysical profiles would be done to assess fetal well-being.

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.

2. Biguanide medication must be held for a test with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems.

The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.

2. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices.

Which of the following is the best method to prevent the spread of infection to an immunosuppressed child? 1. Administer antibiotics prophylactically to the child. 2. Have people wash their hands prior to contact with the child. 3. Assign the same nurses to care for the child each day. 4. Limit visitors to family members only.

2. Hand-washing is the best method to prevent the spread of germs and protect the child from infection.

18. Which assessment data indicate that the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABGs results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

2. The client's level of consciousness can be altered because of dehydration and acido- sis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment.

An 18-month-old male is brought to the clinic by his mother. His height is in the 50th percentile, and weight is in the 80th percentile. The child is pale. The physical examination is normal, but his hematocrit level is 20%. Which of the following questions should assist the nurse in making a diagnosis? Select all that apply. 1. "How many bowel movements a day does your child have?" 2. "How much did your baby weigh at birth?" 3. "What does your child eat every day?" 4. "Has the child been given any new medications?" 5. "How much milk does your child drink per day?"

3, 5. 3. A diet history is necessary to determine the nutritional status of the child and whether the child is getting sufficient sources of iron. 5. By asking how much milk the child consumes, the nurse can determine whether the child is filling up on milk and then not wanting to take food.

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse

A 5-year-old is admitted to the hospital with complaints of leg pain and fever. On physical examination, the child is pale and has bruising over various areas of the body. The physician suspects that the child has ALL. The nurse informs the parent that the diagnosis will be confirmed by which of the following? 1. Lumbar puncture. 2. White blood cell count. 3. Bone marrow aspirate. 4. Bone scan.

3. The diagnostic test that confirms leukemia is microscopic examination of the bone marrow aspirate

In which congenital heart defect (CHD) would the nurse need to take upper and lower extremity BPs? 1. Transposition of the great vessels. 2. Aortic stenosis (AS). 3. Coarctation of the aorta (COA). 4. Tetralogy of Fallot (TOF).

3. With COA there is narrowing of the aorta, which increases pressure proximal to the defect (upper extremities) and decreases pressure distal to the defect (lower extremities). There will be high BP and strong pulses in the upper extremities and lower-than-expected BP and weak pulses in the lower extremities.

During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position? 1. Sitting. 2. Supine. 3. Squatting. 4. Standing.

3. squatting

The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client? _________

3units

16. The client diagnosed with HHS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for urinary ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin therapy.

4. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale.

A newborn is diagnosed with a congenital heart defect (CHD). The test results reveal that the lumen of the duct between the aorta and pulmonary artery remains open.This defect is known as _____________________.

Patent ductus arteriosus or PDA.

A 6-month-old who has episodes of cyanosis after crying could have the congenital heart defect (CHD) of decreased pulmonary blood flow called _____________________.

Tetralogy of Fallot or TOF

For the child with hypoplastic left heart syndrome, which drug may be given to allow the patent ductus arteriosus (PDA) to remain open until surgery? _____________________

the drug indomethacin - prostaglandin inhibitor (used up to 6 doses) A newborn is diagnosed with a congenital heart defect (CHD). The test results reveal that the lumen of the duct between the aorta and pulmonary artery remains open. This defect is known as Patent ductus arteriosus or PDA

A nurse is caring for a client, 28 weeks' gestation, with placenta previa. Which of the following physician orders should the nurse question? Select all that apply. 1. Encourage ambulation. 2. Weigh all vaginal pads. 3. Assess cervical dilation daily. 4. Perform a nonstress test every morning. 5. Administer Colace 100 mg PO three times a day

1 and 3 are correct. Because the placenta could be injured, no vaginal examinations should be performed; therefore, the nurse should question #3—assess cervical dilation daily. Also, because bleeding may occur, clients with placenta previa are allowed only minimal activity; therefore, ambulation would not be encouraged.

Which of the following measures should the nurse implement to help with the nausea and vomiting from chemotherapy? Select all that apply. 1. Give an antiemetic 30 minutes prior to the start of therapy. 2. Continue the antiemetic as ordered until 24 hours after the chemotherapy is complete. 3. Remove food that has a lot of odor. 4. Keep the child on a nothing-by-mouth status. 5. Wait until the nausea begins to start the antiemetic.

1, 2, 3. 1. The first dose should be given 30 minutes prior to the start of the therapy. 2. Antiemetic should be administered around the clock until 24 hours after the chemotherapy is completed. 3. It is also helpful to remove foods with odor so the smell of the food does not make the child nauseated.

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.

1, 2, 4 Fluids are restricted to 500-600 mL per 24 hours. Orientation to person, place, and times should be assess every 2 hours or more often. Urine and serum osmolality are monitored to determine fluid volume status

The nurse is caring for a child who is receiving a transfusion of packed red blood cells. The nurse is aware that if the child had a hemolytic reaction to the blood, the signs and symptoms would include which of the following? Select all that apply. 1. Fever. 2. Rash. 3. Oliguria. 4. Hypotension. 5. Chills.

1, 3, 4. 1. Hemolytic reactions include fever, pain at insertion site, hypotension, renal failure, tachycardia, oliguria, and shock. 3. Hemolytic reactions include fever, pain at insertion site, hypotension, renal failure, tachycardia, oliguria, and shock. 4. Hemolytic reactions include fever, pain at insertion site, hypotension, renal failure, tachycardia, oliguria, and shock.

A child has completed treatment for leukemia and comes to the clinic with the parents for a checkup. The parents express to the nurse that they are glad their child has been cured of cancer and is safe from getting cancer later in life. Which of the following should the nurse consider in responding? 1. Childhood cancer usually instills immunity to all other cancers. 2. Children surviving one cancer are at higher risk for a second cancer. 3. The child may have a remission of the leukemia but is immune to all other cancers. 4. As long as the child continues to take steroids, there will be no other cancers.

2. The most devastating late effect of leukemia treatment is development of secondary malignancy.

Which plan would be appropriate in helping to control congestive heart failure (CHF) in an infant? 1. Promoting fluid restriction. 2. Feeding a low-salt formula. 3. Feeding in semi-Fowler position. 4. Encouraging breast milk.

3. The infant has a great deal of difficulty feeding with CHF, so even getting the maintenance fluids is a challenge. The infant is fed in the more upright position so fluid in the lungs can go to the base of the lungs, allowing better expansion.

A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 25 mg/dL and after a feeding of mother's expressed breast milk is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatalogist of the abnormal glucose levels.

4. If the glucose level has not risen to normal as a result of the feeding, the nurse should notify the physician and anticipate that the doctor will order an intravenous of dextrose and water.

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

1, 2, 5 1. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. 2. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. 5. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1. Assess the client's ability to read small print

During a home visit to an 8-month-old infant in congestive heart failure on digoxin (Lanoxin), the nurse obtains assessment information. Which assessment indicates that the nurse needs to consult the physician? 1. The infant's apical pulse is 70 at rest. 2. After crying, the infant's heart rate is 170. 3. Respirations are 40 per minute at rest. 4. Capillary refill is <3 sec.

1. Bradycardia (heart rate below 90-110 bpm in infants) is a common sign of digoxin toxicity. The provider should be notified

Which physiological changes occur as a result of hypoxemia in congestive heart failure (CHF)? 1. Polycythemia and clubbing. 2. Anemia and barrel chest. 3. Increased white blood cells and low platelets. 4. Elevated erythrocyte sedimentation rate and peripheral edema.

1. The hypoxemia stimulates erythropoiesis, which causes polycythemia, in an attempt to increase oxygen by having more red blood cells carry oxygen. Clubbing of the fingers is a result of the polycythemia and hypoxemia.

Treatment for congestive heart failure (CHF) in an infant began 3 days ago and has included digoxin and furosemide. The child no longer has retractions, lungs are clear, and HR is 96 beats per minute while the child sleeps. The nurse is confident that the child has diuresed successfully and has good renal perfusion when the nurse notes the child's urine output is: 1. 0.5 cc/kg/hr. 2. 1 cc/kg/hr. 3. 30 cc/hr. 4. 1 oz/hr.

2. Normal pediatric urine output is 1 cc/kg/hr.

An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.

2. The nurse would expect the woman to hemorrhage. A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterectomy to control the bleeding. Clients who have had multiple uterine scars are especially at high risk for this problem

A nurse is caring for a 5-year-old with sickle cell vaso-occlusive crisis. Which of the following orders should the nurse question? Select all that apply. 1. Position the child for comfort. 2. Apply hot packs to painful areas. 3. Give Demerol 25 mg intravenously every 4 hours as needed for pain. 4. Restrict oral fluids. 5. Apply oxygen per nasal cannula to keep oxygen saturations above 94%.

3, 4. 3. Tissue hypoxia is very painful. Narcotics such as morphine are usually given for pain when the child is in a crisis. Demerol should be avoided because of the risk of Demerol-induced seizures. 4. The child should receive hydration because when the child is in crisis, the abnormal S-shaped red blood cells clump, causing tissue hypoxia and pain.

Which sign/symptom would the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Excessive thirst. 2. Orthopnea. 3. Ascites. 4. Concentrated urine output.

4. Excess antidiuretic hormone (ADH) causes SIADH, which causes increased water reabsorption and leads to increased fluid volume and scant, concentrated urine.

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output.

1. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia, "and this blood glucose level is within acceptable ranges for a client who is noncompliant.

A 10-month-old with heart failure weighs 10 kg. Digoxin (Lanoxin) is prescribed as 10 mcg/kg/day to be given every 12 hours. How much is given for each dose? 1. 10 mcg. 2. 50 mcg. 3. 100 mcg. 4. 500 mcg.

2. 10 kg × 10 mcg/kg/day = 100 mcg ÷ 2 doses a day = 50 mcg/dose.

A client who had an abdominal aneurysm repair yesterday has a urinary output of 25 mL/hr and a blood urea nitrogen (BUN) of 68 mg/dL. What action should the nurse take first? 1. Call the surgeon immediately 2. Assess the clients vital signs 3. Increase the IV fluid rate 4. Continue to monitor the client

2. assess the client's vital signs

A 25-week-pregnant client, who had eaten a small breakfast, has been notified that her glucose challenge test results were 132 mg/dL 1 hour after ingesting the glucose. Which of the following is appropriate for the nurse to say at this time? 1. "Because you ate before the test, the results are invalid and will need to be repeated." 2. "Because your test results are higher than normal, you will have to have another more specific test." 3. "Because of the results you will have to have weekly glycohemoglobin testing done." 4. "Because your results are within normal limits you need not worry about gestational diabetes.

2. This comment is appropriate. The client will be referred for a 3-hour glucose tolerance test.

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.

3. Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable

A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis? 1. Dark brown rectal bleeding. 2. Severe nausea and vomiting. 3. Sharp unilateral pain. 4. Marked hyperthermia.

3. Sharp unilateral pain is a common symptom of a ruptured ectopic.

The nurse receives a call from a parent of a child with leukemia in remission. The parent says the child has been exposed to chickenpox. The child has never had chickenpox. Which of the following responses is most appropriate for the nurse? 1. "You need to monitor the child's temperature frequently and call back if the temperature is greater than 101°F (38.3°C)." 2. "At this time there is no need to be concerned." 3. "You need to bring the child to the clinic for a chickenpox immunoglobulin vaccine." 4. "Your child will need to be isolated for the next 2 weeks."

3. The child should receive varicella zoster immune globulin within 96 hours of the exposure.

The client is admitted to the medical unit with a diagnosis of rule out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. 2. The client will be given an injection of antidiuretic hormone, and urine output will be measured for four (4) to six (6) hours. 3. The client will be NPO, and vital signs and weights will be done hourly until the end of the test. 4. An IV will be started with normal saline, and the client will be asked to try and hold the urine in the bladder until a sonogram can be done.

3. The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated.

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3. The most common difference between placenta previa and placenta abruption is the absence or presence of abdominal pain.

2. The client diagnosed with Type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

3. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test that reflects average blood glucose levels over a period of 2-3 months; clients with elevated blood glucose levels are at risk for developing long-term complications.

The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective? 1. The client reports being able to breathe through the nose. 2. The client complains of being thirsty all the time. 3. The client has a blood glucose of 99 mg/dL. 4. The client is urinating every three (3) to four (4) hours.

4. Diabetes insipidus is characterized by the client not being able to concentrate urine and excreting large amounts of dilute urine. If the client is able to delay voiding for three (3) to four (4) hours, it indicates the medication is effective.

The nurse is discharging a child who has just received chemotherapy for neuroblastoma. Which of the following statements made by the child's parent indicates a need for additional teaching? 1. "I will inspect the skin often for any lesions." 2. "I will do mouth care daily and monitor for any mouth sores." 3. "I will wash my hands before caring for my child." 4. "I will take a rectal temperature daily and report a temperature greater than 101°F (38.3°C) immediately to the physician."

4. Monitoring the child's temperature and reporting it to the physician are important, but the temperature should not be taken rectally. The risk of injury to the mucous membranes is high. Rectal abscesses can occur in the damaged rectal tissue. The best method of taking the temperature is axillary, especially if the child has mouth sores.

Which finding should the nurse expect when assessing a client with placenta previa? 1. Severe occipital headache. 2. History of renal disease. 3. Previous premature delivery. 4. Painless vaginal bleeding.

4. Painless vaginal bleeding is often the only symptom of placenta previa.

The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which nursing intervention should be implemented? 1. Monitor blood glucoses before meals and at bedtime. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is 250. 4. Assess tissue turgor every four (4) hours.

4. The client is excreting large amounts of dilute urine. If the client is unable to take in enough fluids, the client will quickly be- come dehydrated, so tissue turgor should be assessed frequently.

23. Which arterial blood gas would the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.

4. This ABG indicates metabolic acidosis, which is what is expected in a client that is in diabetic ketoacidosis.

The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cool-down exercises.

4. perform warmup and cool down exercises

A child with leukemia received chemotherapy about 10 days ago. She presents today with a temperature of 100.4°F, an absolute neutrophil count of 500, and mild bleeding of the gums. What is the priority nursing intervention? a. Administer IV antibiotics as ordered. b. Provide vigorous oral care frequently with a firm toothbrush. c. Monitor pulse and blood pressure for changes. d. Administer packed red blood cell transfusion.

a. The neutropenic child must have IV antibiotics started as soon as possible in the event of fever to prevent overwhelming infection and sepsis.

A 5-year-old has been diagnosed with Wilms tumor. What is the priority nursing intervention for this child? a. Educate the parents about dialysis, as the kidney will be removed. b. Measure abdominal girth every shift. c. Avoid palpating the child's abdomen. d. Monitor BUN and creatinine every 4 hours.

c. Excessive palpation of the abdomen in a child with Wilms' tumor can cause seeding of the tumor, leading to metastasis.

A child with cancer is receiving chemotherapy, and his mother is concerned that the nausea and vomiting associated with chemotherapy are reducing his ability to eat and gain weight appropriately. What is the most appropriate nursing action? a. Administer an antiemetic at the first hint of nausea. b. Offer the child's favorite foods to encourage him to eat. c. Start antiemetic drugs prior to the chemotherapy infusion. d. Maintain IV fluid infusion to avoid dehydration.

c. Give the antiemetic prior to the chemotherapy drug to prevent nausea and vomiting.

The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply. 1. Tell the client to exercise three (3) times a week for 30 minutes. 2. Encourage the client to eat a low-fat, low-cholesterol diet. 3. Instruct the client to decrease tobacco use. 4. Discuss the importance of losing weight with the client. 5. Teach the client to wear a truss at all times.

1. The most common cause of AAA is atherosclerosis, so teaching should address this area. 2. A low-fat, low-cholesterol diet will help decrease development of atherosclerosis 4. Losing weight will help decrease the pressure on the AAA and will help address decreasing the cholesterol level

The parents of a 3-month-old ask why their baby will not have an operation to correct a ventricular septal defect (VSD). The nurse's best response is: 1. "It is always helpful to get a second opinion about any serious condition like this." 2. "Your baby's defect is small and will likely close on its own by 1 year of age." 3. "It is common for physicians to wait until an infant develops respiratory distress before they do the surgery." 4. "With a small defect like this, they wait until the child is 10 years old to do the surgery."

2. Usually a VSD will close on its own within the first year of life.

Which medical treatment would be prescribed for the client with an AAA less than 3 cm? 1. Ultrasound every six (6) months. 2. Intravenous pyelogram yearly. 3. Assessment of abdominal girth monthly. 4. Repair of abdominal aortic aneurysm.

1. When the aneurysm is small (<5 to 6 cm), an abdominal sonogram will be done every six (6) months until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than possible complications of an abdominal aortic aneurysm repair

Which client would be most likely to develop an abdominal aortic aneurysm? 1. A 45-year-old female with a history of osteoporosis. 2. An 80-year-old female with congestive heart failure. 3. A 69-year-old male with peripheral vascular disease. 4. A 30-year-old male with a genetic predisposition to AAA.

3. The most common cause of AAA is atherosclerosis (which is the cause of peripheral vascular disease); it occurs in men four (4) times more often than women and primarily in Caucasian

A client, G2P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? 1. "When did you have your pregnancy test done?" 2. "When was the first day of your last menstrual period?" 3. "Did you have any complications with your first pregnancy?" 4. "How old were you when you first got your period?"

2. The date of the last menstrual period will assist the nurse in determining how many weeks pregnant the client is.

Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position with the legs elevated. 2. Discuss a heart transplant, which is the definitive treatment. 3. Prepare the client for coronary artery bypass graft. 4. Teach the client to take a calcium channel blocker in the morning.

2. Without a heart transplant, this client will end up in end-stage heart failure. A transplant is the only treatment for a client with dilated cardiomyopathy

The parent of a child diagnosed with Wilms tumor asks the nurse what the treatment plan will be. The nurse explains the usual protocol for this condition. Which information should the nurse give to the parent? 1. The child will have chemotherapy and, after that has been completed, radiation. 2. The child will need to have surgery to remove the tumor. 3. The child will go to surgery for removal of the tumor and the kidney and will then start chemotherapy. 4. The child will need radiation and later surgery to remove the tumor.

3. Combination therapy of surgery and chemotherapy is the primary therapeutic management. Radiation is done depending on clinical stage and histological pattern.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1500 mL and an output of 1600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.

3. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize.

A gravid client, G6P5005, 24 weeks' gestation, has been admitted to the hospital for placenta previa. Which of the following is an appropriate long-term goal for this client? 1. The client will state an understanding of need for complete bedrest. 2. The client will have a reactive nonstress test on day 2 of hospitalization. 3. The client will be symptom-free until at least 37 weeks' gestation. 4. The client will call her children shortly after admission.

3. That the client be symptom-free until at least 37 weeks' gestation is a long-term goal. At that time, the baby will be full term.

The nurse is caring for a child after a cardiac catheterization. What is the nursing priority? 1. Allow early ambulation to encourage activity participation. 2. Check pulses above the catheter insertion site for strength and quality. 3. Assess extremity distal to the insertion site for temperature and color. 4. Change the dressing to evaluate the site for infection.

3. Vessel spasm or hematoma may occur after the catheterization, occluding circulation. The extremity may become pale, feel cool to the touch, and have diminished pulses distal to the insertion site.

A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The flow of blood through the heart is _____________________.

Left to right. The pressures in the left side of the heart are greater, causing the flow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood flow with the extra blood.