Practice Bank 1-15RN Practice Question Banks 1-15.pdf

The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of these statements is the best advice about sun protection for this child? "Liberally apply a sunscreen with a minimum sun protective factor of 15 all over the body." "Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." "Sunscreen should not be used on children." "You should keep the baby inside unless it's cloudy outside."

"Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned while near water. A hat and light protective clothing should be worn. Sunscreen is not generally recommended for infants under the age of 6 months; however, the American Academy of Pediatrics states that it can be applied to small areas of the baby's skin that are exposed to the sun (such as the baby's face or the back of the hands).

A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching? "I can take it off when I shower or take a bath." "I should inspect my skin under the brace every day" "The brace has to be worn all day and night." "I will only have to wear this for six months."

"I will only have to wear this for six months." The Milwaukee brace, also known as a cervico-thoraco-lumbo-sacral orthosis or CTLSO, is a back brace used in the treatment of spinal curvatures such as scoliosis or kyphosis in children. It is a full-torso brace that extends from the pelvis to the base of the skull.The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. The client's statement about only having to wear it for 6 months is incorrect and indicates a need for additional teaching. The other statements indicate a correct understanding.

The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? Monitor for hyperkalemia Use careful repositioning techniques Administer diuretics as ordered Place in protective isolation

Careful repositioning Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures. Correct!

A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings? Double vision and visual halos Confusion and light-headedness Photosensitivity and photophobia Extremity tingling and numbness

Extremity tingling and numbness Peripheral neuropathy is a common side effect of isoniazid and other antitubercular medications and should be reported to the health care provider. Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use.

A nurse is caring for a 74 year-old client with benign prostatic hypertrophy (BPH). Which finding would the nurse anticipate when assessing this client? Large volume of urinary output with each voiding Frequent urination Involuntary voiding with coughing and sneezing Urine is dark and concentrated

Frequent urination

A client has received two units of whole blood today after an episode of gastrointestinal bleeding. Which laboratory report should the nurse be sure to monitor closely? Platelets Hemoglobin and hematocrit White blood cells Bleeding time

Hemoglobin and hematocrit The post-transfusion hematocrit provides immediate information about red cell replacement and if there is any continued blood loss; the follow-up hematocrit should be checked around 4 to 6 hours after the infusion is completed.

During a situation of pain management, which statement is a priority to consider for the ethical guidance of a nurse? Clients have the right to have their pain relieved Cultural sensitivity is fundamental to pain management The client's self-report is the most important consideration Nurses should not prejudge a client's pain using their own values

The client's self-report is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important consideration.

A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." What is the best response by the nurse to this statement? "Have you thought about hurting yourself?" "Think of the many positive things in life today." "Did you tell any of this to your family?" "Come on, it is not that bad."

"Have you thought about hurting yourself?" It is most important to determine whether someone who voices thoughts about death is considering suicide (i.e. suicidal ideation). Individuals may provide both behavioral and verbal clues as to the intent of their acts. Behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes and demonstrating a sudden lift in mood. Verbal clues may be both direct and indirect. An example of a direct statement includes, "I want to die." An example of an indirect statement includes, "I don't have anything worth living for anymore". This client's statement indicates suicidal ideation and the client's safety is the highest priority. The nurse should ask the client directly about thoughts or plans to harm themselves. The other responses are not therapeutic and will not help identify if the client is at risk for suicide. The best statement by the nurse follows the nursing process by collecting more data about the client's statement.

The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective? "I may experience seizures if I stop the medication abruptly." "I will expect to feel nervousness the first few weeks." "I can have a heart attack if I stop this medication suddenly." "I could have an increase in my heart rate for a few weeks."

"I can have a heart attack if I stop this medication suddenly." Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart attack.

The nurse is admitting a client who is newly diagnosed with a frontal lobe brain tumor. Which statement made by a spouse may provide important information about this diagnosis and should be communicated to the health care provider? "I find the mood swings and the change from being a calm person to being angry all the time hard to deal with." "It seems our sex life is nonexistent over the past six months." "In the morning and evening he complains that reading is next to impossible because the print is blurry." "His breathing rate is usually below 12."

"I find the mood swings and the change from being a calm person to being angry all the time hard to deal with." The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

At a senior citizen's group meeting the nurse talks with a client who has type 1 diabetes. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? "I give my insulin to myself in my thighs and belly and alternate sites." "Here are my glucose test readings that I wrote on my calendar." "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" "If I bathe more than once a week my skin feels too dry."

"I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairment.

A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? "I am surprised that you are upset. The request could have waited a few more minutes." "I apologize for the delay. I was involved in an emergency." "Let's talk. Why are you upset about this?" "I see this is frustrating for you. I have a few minutes so let's talk."

"I see this is frustrating for you. I have a few minutes so let's talk." This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs.

The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "My child has lost three pounds in the last month." "The child prefers some salty foods more than others." "All the pants have become tight around the waist." "Urinary output seems to be less over the past two days."

"Urinary output seems to be less over the past two days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse.

A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement? "You have been exposed to the organism Mycobacterium tuberculosis." "This means you have never had or been around someone with tuberculosis." "You most likely have a resistant form of active tuberculosis." "You are mostly likely have a natural immunity to the bacteria."

"You have been exposed to the organism Mycobacterium tuberculosis." The PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB.

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a nearby chair. The mother states, "This is not my baby, and I do not want it." After repositioning the child safely, the nurse should respond with which comment? "You seem upset. Tell me what the pregnancy and birth were like for you." "Many women have postpartum blues and need some time to love the baby." "What a beautiful baby! Her eyes are just like yours and so is her smile." "This is a common occurrence after birth, but you will come to accept the baby."

"You seem upset. Tell me what the pregnancy and birth were like for you." A nonjudgmental, open ended response facilitates dialogue between the client and the nurse. The other three options ignore the situation and the needs of the mother. Note that the correct answer is the only client-centered option that is directly associated with the given situation.

Which individual is at greatest risk for the development of hypertension? 55 year-old Hispanic teacher 40 year-old Caucasian nurse 60 year-old Asian-American shop owner 45 year-old African-American attorney

45 year-old African-American attorney The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising.

The clients listed below are all using patient-controlled analgesic (PCA) pump for pain control. Which of these clients is least appropriate to use a PCA pump? A 4-year-old preschooler with intermittent episodes of alertness A 16-year-old teenager who reads at a 4th-grade level A 71-year-older adult client with numerous arthritic nodules on the hands A 25-year-old young adult with a history of Down syndrome

A 4-year-old with intermittent episodes of alertness The 4-year-old client (preschool-aged) is most likely to have difficulty with the use or understanding of a patient-controlled analgesia (PCA) pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School age children, ages 6 and up, are better candidates for PCA electronic pumps.

A nurse is working with one licensed practical nurse (LPN) and a mental health tech (an unlicensed assistive personnel). Which newly admitted client would be appropriate to assign to the mental health tech? An adolescent diagnosed with dehydration and anorexia A young adult who reports to be a heroin addict and states, "I am in withdrawal and seeing spiders." A middle-aged client diagnosed with an obsessive compulsive disorder A 76 year-old client diagnosed with severe depression

A middle-aged client diagnosed with an obsessive compulsive disorder The mental health tech (a type of unlicensed assistive personnel or UAP) can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition and has a situation of expected outcomes.

An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A 45-middle-aged person with second and third degree burn (deep abrasions) that are over 90% of the body An infant with bilateral fractured lower legs with no active bleeding An older adult person with a open fracture of the left arm A teenager with small amount of bright red blood dripping out of the nose

A middle-aged person with deep abrasions that are over 90% of the body The clients that are least likely to survive are to be tagged as the "last to be seen= back=" Deep abrasions are usually treated as second or third degree burns because the fluid loss is great This increases the ability to provide treatment to victims who have a greater chance of survival. Fractures are treatable with splinting and immobilization. It is a positive sign that the infant is alert and crying. The client with minor bleeding from the nose should be evaluated for head trauma, but appears stable at this time. A client with burns over 90% of their body will experience massive fluid loss and the burn injuries will most likely be fatal. Therefore, this client should receive a black tag or be seen last.

The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? Absent left pedal pulse using Doppler analysis Inability to palpate the left pedal pulse Left foot is cool to the touch Acute pain in the left lower leg

Absent left pedal pulse using Doppler analysis Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider.

A client has returned from a cardiac catheterization that was two hours ago. Which finding would indicate that the client has a potential complication from the procedure? Absent pedal pulse in the affected extremity Increased blood pressure Decreased urine output Increased heart rate

Absent pedal pulse in the affected extremity Loss of the pulse in the extremity would indicate a potential severe spasm of the artery or clot formation to the extent of an occlusion below the site of insertion. It is not uncommon that initially the pulse may be intermittently weaker from the baseline. However, a total loss of the pulse is a nursing emergency. The health care provider needs immediate notification.

A client is admitted with severe injuries resulting from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. What should be the initial nursing intervention? Administer oxygen as ordered Initiate continuous blood pressure monitoring Institute continuous cardiac monitoring Initiate the ordered intravenous therapy

Administer oxygen as ordered Early findings of shock are associated with hypoxia and manifested by a rapid heart rate and rapid respirations. Therefore, oxygen is the most critical initial intervention; the other interventions are secondary to oxygen therapy.

The nurse is developing a teaching plan for parents on safety and risk-reduction in the home. Which of the following should the nurse give priority consideration to during teaching? Age of children in the home Number of children in the home Age and knowledge level of the parents Proximity to emergency services

Age of children in the home Age and developmental level of the child are the most important considerations in the provision of a framework for anticipatory guidance associated with safety, and should be given priority when teaching safety.

A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? Altered tissue perfusion (Assess the client's cardiac output) Assess the client's level of Assess the client's intolerance Risk for fluid volume excess

Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority.

At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first? 25-year-old young woman, first-time para, cervical dilation to 1 cm and contractions 15 minutes apart A 34-year-old middle-aged woman with a history of two prior vaginal term births and who is 2 cm dilated A 17-year-old adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum A 28-year-old young woman who is a grand multipara, cervical dilation to 4 cm and is 50% effaced

An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum The 18 year-old client has an actual complication of left-sided heart failure and a possible stillborn birth. The other clients present with findings of potential, but not actual, complications. The nurse should see the client who is coughing up frothy sputum first.

Following an alert of an internal disaster and the need for beds, the charge nurse is asked to list the clients who can potentially be discharged. Which one of these clients should the charge nurse select? An adolescent admitted the previous evening with Tylenol intoxication An older adult client with an implantable cardiac defibrillator (ICD) admitted yesterday after receiving multiple shocks An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis A school-aged child admitted earlier today with a diagnosis of suspected bacterial meningitis

An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis The client with type 1 diabetes is the only one with a chronic condition who has been treated for more than a day and whose condition is the most stable. The other clients' conditions are either unstable and/or more acute. Tylenol intoxication requires at least three to four days of intensive observation for the risk of hepatic failure. Because acute bacterial meningitis can lead to permanent brain damage or death, treatment must be started as soon as possible. It is considered a medical emergency for someone with an ICD who experiences multiple shocks.

The charge nurse is scheduled duties in the unit. Which of these clients should a charge nurse assign to a licensed practical nurse (LPN)? A 63 year-old confused client whose family complains about the nursing care two days after the client's surgery An 76-older adult client diagnosed with cystitis and an indwelling urethral catheter A 64-year-old client admitted with the diagnosis of possible transient ischemic attack with unstable neurological signs A 31 year-old trauma victim with multiple lacerations that require complex dressings

An older adult client diagnosed with cystitis and an indwelling urethral catheter The most stable client is the one diagnosed with cystitis. Care for this client has predictable outcomes and there is only a minimal risk for complications. The other clients require more complex care and independent, specialized nursing knowledge, skill or judgment that only an RN can provide.

The nurse is preparing to administer albuterol inhaled to a 11 year-old with asthma. Which assessment by the nurse indicates there is a need for the health care provider to adjust the medication? Temperature of 101 F (38.3 C) Lethargy Apical pulse of 112-116bpm Lower extremity edema

Apical pulse of 112 One of the more common adverse effects of beta adrenergic medications such as albuterol (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA), is an increase in heart rate. Normal resting heart rate for children 10 years and older is the same as adults: 60-100 beats per minute.

A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority? Drying the cast using a hair dryer set to "warm" Use the crossbar to help turn the child from side to side Position the child flat in bed, repositioning from back to stomach every two to four hours Apply waterproof plastic tape to the cast around the genital area

Apply waterproof plastic tape to the cast around the genital area The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer (set to cool) may be used to help dry the cast.

The nurse, who is participating in a community health fair, assesses the health status of attendees. When would the nurse conduct a mental status examination? (All clients participating in the event) There are obvious signs of depression As part of every health assessment The individual displays restlessness The individual reports memory lapses

As part of every health assessment A mental status assessment is a critical part of baseline information and should be a part of every examination.

A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Ask the client to explain what she has taken and how often, and then evaluate other specific complaints Advise the client to have someone bring her to the emergency room as soon as possible Ask the client to stay on the line, get the address, and send an ambulance to the home Advise the client that the swings in her hormones may be the problem; suggest that she call her health care provider

Ask the client to stay on the line, get the address, and send an ambulance to the home The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery.

A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take? Check for any increase in the amount of drainage Call the health care provider as soon as possible Reposition the client to improve the level of comfort Assess the chest tube dressing, tubing and drainage system

Assess the chest tube dressing, tubing and drainage system The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in the water-seal chamber right after surgery indicates an air leak from the pleural space; this is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the CDU, such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and assessing the lungs. After the initial post-operative period, the nurse will assist the client to change positions and cough and deep breath to help re-expand the lung and promote fluid drainage.

The client is scheduled for coronary artery bypass. Based on principles of teaching and learning, what is the best initial approach by the nurse during pre-op teaching? Assess the client's learning style Mail a videotape to the home Tour the coronary intensive unit Administer a written pretest

Assess the client's learning style As with any anticipatory teaching, assessment of the client's level of knowledge and learning style should occur first. If possible, the three senses of hearing, seeing and touching should be used during any teaching to enhance recall.

The RN is planning the care of an 80 year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse? Perform a head to toe assessment. (Assessment of the integumentary condition) Report the finding of any break in the skin Apply lotion to unaffected areas by the fall Identification of a change in skin color

Assessment of the integumentary condition The RN is responsible to conduct a thorough assessment and evaluation of all body systems for this client. The nurse would document information collected during the focused assessment, such as changes in skin color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility.

The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care, and all staff are invited to participate in the study if they wish. This affirms which ethical principle? Autonomy Anonymity Beneficence Justice

Autonomy Individuals must be free to make independent decisions about participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act.

The client is diagnosed with gastroesophageal reflux disease (GERD). Which recommendation made by the nurse would be most helpful? Maintain a diet of soft foods and cooked vegetables Avoid liquids unless a thickening agent is used Sit upright for at least half an hour after eating Avoid eating two hours before going to sleep

Avoid eating two hours before going to sleep

The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize? Add complex carbohydrates to each meal Avoid large and heavy meals Limit sodium to 7 grams per day Eat three balanced meals a day

Avoid large and heavy meals Eating large, heavy meals can pull blood away from the heart for the digestion process. This may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the size of the meal, which is more important.

A nurse is teaching a client to select foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands this dietary requirement and recognizes which foods are highest in potassium? Naval orange Baked potato Small banana Three apricots

Baked potato contains 610 milligrams of potassium. Apricots, oranges and bananas do have higher potassium content, but because of their size they are not the highest in potassium. A baked potato is the highest in potassium of the given options.

The nurse working in the intensive care unit (ICU) is told that a client is being newly admitted with a diagnosis of hyperglycemic hyperosmolar nonketotic state (HHNS). The nurse would expect which of the following clinical findings in this client? (Select all that apply.) Blood glucose level of at least 600 mg/dL Ketonuria History of type 1 diabetes mellitus Metabolic acidosis Severe dehydration

Blood glucose level of at least 600 mg/dL Severe dehydration

The nurse is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment during this treatment? Heart rate Neurologic status Blood pressure Urine output

Blood pressure The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin also require continuous ECG monitoring.

Which finding should alert the nurse to the possible presence of a cataract in a client? Dull aching in the eye and eyelids Nearsightedness and loss of peripheral vision Farsightedness and loss of central vision Blurred vision and reduced color perception

Blurred vision and reduced color perception As the lens becomes opaque and less able to refract light appropriately, the client will experience blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision and visual acuity, nor does it result in aching of the eye or eyelids.

Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? Interrupt, apologize for interruption, and change the subject Adjourn the meeting and reschedule when everyone has calmed down Tell the violators they must calm down and be reasonable Bring the communication focus back to the client

Bring the communication focus back to the client Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse.

There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? Squeeze one drop of the medication in the left eye every 4 hours Apply one drop in the right ear every 4 hours Call the prescriber to clarify and rewrite the order Ask other nurses for their interpretation of the order

Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order.

A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Test deep tendon reflexes Check blood calcium level Check complete blood count (CBC) with differential Check serum potassium level

Check complete blood count (CBC) with differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ.

The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Place the client into the bed and administer the ordered PRN analgesic Measure the client's respirations, blood pressure, temperature and pupillary responses Check the client for bladder distention and the urinary catheter for kinks Assist client with relaxation techniques

Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.

The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion? Measure the length of tubing from nose to epigastrium Check the pH of the aspirate Auscultate the abdomen while instilling 10 mL of air into the tube Place the end of the tube in water to check for air bubbles

Check the pH of the aspirate Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations include assessing the feeding tube placement by testing the pH of aspirates, measuring the external portion of the tube, and observing for changes in the volume and appearance of feeding tube aspirates. If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that are no longer recommended.

The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy? Photophobia and sun sensitivity Constipation Hematuria Chills and fever

Chills and fever Biological response modifier cancer therapy agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side effects of this type of therapy. The other assessment findings are not what you would expect when the body is fighting pathogens.

A nurse is teaching adolescents about sexually transmitted diseases. What should the nurse emphasize is the most common infection? Gonorrhea Human immunodeficiency virus (HIV) Herpes Chlamydia

Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. Prevention is similar to safe sex practices taught to prevent any sexually transmitted disease, such as abstinence, and the use of a condom and spermicide for protection during intercourse. This infection has subtle findings so the infected persons are less likely to pursue medical attention.

An 88 year-old client is admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin dependent diabetes and a previous myocardial infarction. The nurse responds to the client's ECG alarm and finds the client's rhythm shows asystole and the client obtunded but responsive. Prioritize the actions of the nurse (with 1 being the top priority). Initiate emergency response system if indicated Assess respirations and pulse Look at a different ECG lead to confirm rhythm Check a blood glucose level

Confirm ECG lead placement Check level of consciousness Assess respirations and pulse Initiate emergency response system if indicated Obtain a blood glucose level After checking responsiveness, establishing a patent airway and then assessing breathing and circulation are the next priorities (ABCs). This assessment would provide information to decide whether the emergency response team is needed. Because the client is responsive, the monitor rhythm is not correct, as a client with asystole would be unresponsive. Asystole on a rhythm strip may simply be a loose lead; a quick way to check this is to select another lead. The client's obtunded state indicates that ion is needed, so assessment of a central pulse and blood pressure is indicated to determine whether cardiovascular compromise is responsible for this condition. If no evidence of an immediate cardiac event is present, the blood glucose should be checked. Stress and changes in food or fluid consumption secondary to surgery increase the risk of glucose imbalance in the person with diabetes.

A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action? Turn the client back to the original position Continue to monitor the rate of drainage Check to see if the client has a type and cross match Call the surgeon immediately

Continue to monitor the rate of drainage Following a lobectomy, it is not unusual for blood to collect in the chest and be released into the chest drainage system when the client changes positions. This is most common in the immediate, post-operative phase. The dark color of the blood indicates it is likely old blood and there is not active bleeding inside of the chest. Sanguineous drainage should be expected within the initial 24 hours post-op, progressing to serosanguineous, and then to a serous type. If the drainage exceeds approximately 100 mL in one hour, then the nurse should call the surgeon. In this case, the nurse should continue to monitor the rate of the drainage.

The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group) manual for which purpose? Implement nursing care based on case management protocol Determine reimbursement for a medical diagnosis Classify nursing diagnoses from the client's health history Identify findings related to a medical diagnosis

Determine reimbursement for a medical diagnosis DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment

The nurse is providing discharge teaching to a client who has had a total hip prosthesis implanted. During teaching, the nurse should include which content in the instructions for home care? Ambulate using crutches only Sleep only on your back and not on your side Avoid climbing stairs for three months Do not cross your legs at the ankles or knees

Do not cross your legs at the ankles or knees These clients should avoid the bringing of the knees together. Clients are to use a pillow between their legs when lying down and can lie on the back or side. Crossing the legs or bringing the knees together results in a strain on the hip joint. This increases the risk of a malfunction of the prosthesis where the ball may pop out. A walker or crutches may be used as assistive devices. These and other precautions are minimally followed for six weeks postoperative and sometimes longer as indicated.

The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. What is the most important instruction about exercise? Use exercise to strengthen muscles and protect bones Exercise to reduce weight over a few months Avoid exercise activities that increase the risk of fracture Do weight-bearing or resistance activities

Do weight-bearing or resistance activities Weight-bearing or resistance exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes these exercises. In addition, other approaches are estrogen replacement and calcium supplements in a treatment protocol.

A nurse is teaching a class on human immunodeficiency virus (HIV) prevention. Which activity should be cautioned against since it is shown to increase the risk of HIV? Use of public bathrooms in any city Engaging in unprotected sexual encounters Physical touch of a person with autoimmune deficiency syndrome (AIDS) Donation of blood to the state agencies

Engaging in unprotected sexual encounters

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process? Fetal heart rate is 188 beats/minute Cervical dilation of 4 centimeters Blood pressure is 138/88 mm Hg Maternal temperature is 100 F (37.7 C)

Fetal heart rate is 188 beats/minute Prolonged ruptured membranes may lead to maternal infection (as suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188; fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and administer oxygen and intravenous fluids.

The nurse is caring for a client with breast cancer who received chemotherapy one week ago. Which finding is the priority to report to the health care provider? Fever and chills Discomfort in both breasts Skin tenting of the forearm Depressed mood

Fever and Chills Chemotherapy causes myelo or bone marrow suppression, resulting in neutropenia, the reduction in neutrophils (white blood cells) that fight off infections. Neutropenic, i.e., immunocompromised, clients are at an increased risk for infection, sepsis and septic shock and the nurse has to be extra vigilant in monitoring for early signs of infection. A fever and chills are indicative of a possible infection and take priority to be reported to the HCP. The other findings are also important to note and should be addressed by the nurse after notifying the HCP of the fever and chills.

The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure? Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn Supplemental oxygen should be turned off 30 minutes prior to collecting the sample The femoral artery is the preferred sample site The blood sample must be kept at room temperature and delivered to the lab as soon as possible

Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes. Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical reactions in the blood.

The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What nursing action is needed before starting the infusion? (Select all that apply.) Flush the tube with 30 mL of warm water Keep the feeding product refrigerated until ready to use Palpate the abdomen Milk or massage the tube Elevate the head of the bed 30-45 degrees Verify the length and placement of the tube

Flush the tube with 30 mL of warm water Elevate the head of the bed 30-45 degrees Verify the length and placement of the tube Prior to starting every feeding, the nurse should verify the length and placement of the tube, flush the tube with 30 mL of warm (not hot and not cold) water, and elevate the head of the client's bed at least 30 degrees. The nurse should also verify the presence of bowel sounds before starting the infusion. There's no need to milk the tube unless it's obstructed. Feeding products should be brought to room temperature before the infusion to prevent gastrointestinal discomfort.

A pregnant client, at 34-weeks gestation, is diagnosed with a pulmonary embolism (PE). Which of these medications does the nurse anticipate the health care provider will initially order? Warfarin (Coumadin) therapy every other day to maintain a PT at 1.5 to 2 times the control value Subcutaneous heparin 5000 units twice a day Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value Low dose aspirin therapy

Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value Clients diagnosed with PE, whether pregnant or not, are initially treated with intravenous unfractionated heparin (UFH). The client's activated partial thromboplastic time (aPTT) should be monitored and kept in the therapeutic range of between 1.5 to 2 times the baseline value. Alternatively, low molecular weight heparins, such as enoxaparin (Lovenox), can be used to treat PE in women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant properties, low dose aspirin therapy (81 mg), with or without heparin, is more often used prophylactically to prevent the development of deep vein thrombosis.

The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? Sodium-restricted Dairy-free High fat, high-calorie Gluten-free, low fiber

High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten-free diet.

There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication? High serum creatinine Low serum blood urea nitrogen Low serum albumin High gastric pH

High serum creatinine Gentamicin is excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for toxicity. Reduced renal function will delay the excretion of many medications.

A nurse is teaching home care to the parents of a child diagnosed with acute spasmodic croup. What type of care would be most important to emphasize? Sedation as needed to prevent exhaustion Humidified air with an increase in oral fluids Antibiotic therapy for 10 to 14 days Antihistamines to decrease allergic responses

Humidified air with an increase in oral fluids The most important aspects of home care for a child diagnosed with acute spasmodic croup are humidified air and increased oral fluids. Humidified air helps reduce vocal cord swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce night time symptoms. Adequate systemic hydration aids mucociliary clearance by keeping secretions thin and easy to remove with minimal coughing effort.

A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown? Sigmoid colostomy Ileostomy Ileal conduit Transverse colostomy

Ileostomy which is from the small intestine, is of continuous, liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on skin can denude skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to the abdominal wall.

During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions? Increase fluids that are high in protein Instruct the client to increase fluid intake for the next two days Restrict fluids for the next few hours (2 hours) Instruct client to increase fluid intake for several hours

Instruct client to increase fluid intake for several hours This client is experiencing postural hypotension, a decrease in systolic blood pressure 15 mm Hg accompanied by an increase in heart rate 15 to 20 beats above the baseline with a change in position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, but must be instituted very cautiously, as this client with cardiomyopathy will also be very sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension.

A pregnant client at 34 weeks gestation is diagnosed with a pulmonary embolism. Which of these medications should the nurse plan to administer? Subcutaneous enoxaparin Oral warfarin Intravenous heparin Oral low-dose aspirin

Intravenous heparin Clients diagnosed with pulmonary embolism (PE), whether pregnant or not, are initially treated with intravenous unfractionated heparin. Alternatively, low molecular weight heparin such as enoxaparin can be used to treat women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant properties, low-dose aspirin therapy (81 mg) is more often used prophylactically, not for the treatment of a PE.

The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? It will reduce serum calcium Amphojel increases urine output The drug is taken to control gastric acid secretion It decreases serum phosphate

It decreases serum phosphate Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate.

A nurse is providing a parenting class to individuals living in a community of older homes that were built prior to 1978. During a discussion about formula preparation, which statement is the most important by the nurse to tell the parents how to prevent lead poisoning? Boil the tap water for 10 minutes prior to preparing the formula Buy bottled water labeled "lead free" to mix with the formula Use ready-to-feed commercial infant formula Let tap water run for two minutes before adding to formula concentrate

Let tap water run for two minutes before adding to formula concentrate The use of lead-contaminated water to prepare infant formula is a major source of lead poisoning in infants who live in older houses. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in homes prior to 1978. Letting tap water run for several minutes will diminish the risk for lead contamination. These same houses have the risk of lead contamination from paint chips because prior to that time, paint and gasoline contained lead.

A young adult seeks treatment in an outpatient mental health center. The client tells the nurse: "I am a government official being followed by spies." On further questioning, the client reveals: "My warnings must be heeded to prevent nuclear war." Which of the following actions should the nurse take? Ask for more information about the spies Listen quietly without comment Confront the client's delusion Contact the government agency

Listen quietly without comment The client's comments demonstrate grandiose ideas. The most therapeutic response is to listen but to also avoid being pulled into the client's delusional system. At some point validation of the present situation will need to be done. Confrontation at this time would be an inappropriate action and is not therapeutic.

A community health nurse has been caring for a 16 year-old who is 22-weeks pregnant with a history of morbid obesity, asthma and hypertension. Which of these lab reports need to be communicated to the health care provider as soon as possible? Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.2 μmol/L) Hemoglobin 11 g/dL (110 g/L) and calcium 6.7 mg/dL (1.68 mmol/L) Blood urea nitrogen 28 mg/dL (10 mmol/L) and glucose 225 mg/dL (12.4 mmol/L) Hematocrit 33% (0.33) and platelets 200,000 μL

Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.2 μmol/L)

The nurse is caring for a client in a violent relationship. The nurse should understand that immediately after an acute battering incident, the batterer may respond to the partner's injuries by taking which action? Minimize the episode with an underestimation of the victim's injuries Be very remorseful and assist the victim to receive medical care Seek medical help for the victim's injuries Contact a close friend and ask for help with the incident

Minimize the episode with an underestimation of the victim's injuries Many batterers lack an understanding of the effects of their behavior on the person who was battered. Batterers use excessive minimization and denial of the situation and their behaviors or intent.

The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Administer the ordered PRN medication Reassess the extremity in 15 minutes Readjust the traction for comfort Notify the health care provider

Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.

The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? Chloride 100 mEq/L (100 mmol/L) Sodium 130 mEq/L (130 mmol/L) Hemoglobin 15 g/dL (150 g//L) PaCO2 30 mm Hg

PaCO2 30 mm Hg Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both males and females. The chloride and sodium results are also WNL.

A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse? Chewable aspirin is the preferred analgesic Recommend an antiviral medication to relieve itching The illness is only contagious when the lesions are present Papules, vesicles and crusts will be present at one time

Papules, vesicles and crusts will be present at one time All three stages of the chickenpox lesions will be present on the child's body at the same time. Children should not be medicated with aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to two days before their blisters appear and remain contagious until all the blisters have crusted over. Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter hydrocortisone creams can help relieve itchy skin.

The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? Able to ambulate in the hallway with assistance Post-operative pain is managed Able to tolerate a regular diet Psychological counseling is scheduled

Post-operative pain is managed An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority.

Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse anticipates their reaction to be in which phase of the crisis process? Impact phase Resolution phase Pre-crisis phase Crisis phase

Pre-crisis phase A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. The development of a crisis situation follows a relatively predictable course. Stages in a crisis go from the pre-crisis phase (phase 1) , to the impact phase (phase 2), then the crisis phase (phase 3), and finally the resolution phase (phase 4). The time frame of recent bad news places the parents in phase 1. In this phase, an individual is exposed to a precipitating stressor, resulting in increased anxiety and employment of previous problem-solving techniques. There is no data to determine their response phase except the time frame of recent bad news. The impact of crisis is indicative of high levels of stress, sense of helplessness, confusion, disorganization, and the inability to apply problem-solving behavior.

The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority? Change the dressing over the site of the existing CVAD Insert an indwelling catheter Prepare the client for insertion of a new CVAD Restrict contact with persons having known, or recent, infections

Prepare the client for insertion of a new CVAD Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source of the infection, it should be cultured and removed. A new central line (usually an internal jugular or subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The new central line will also allow venous access for labs, medications and measuring central venous pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent infections to help protect all clients.

The nurse is evaluating a developmentally challenged 2 year-old child. During the evaluation, what goal should the nurse stress when talking to the child's mother? Prepare for independent toileting Teach the child self-care skills Promote the child's optimal development Help the family decide on long-term care

Promote the child's optimal development The primary goal of nursing care for a developmentally challenged child is to promote the child's optimal development. The child should be supported and encouraged to learn and grow to their fullest potential. Self-care and toileting may not be appropriate goals for the child due to the cerebral palsy. It is premature to discuss if the child should be placed in a long-term care facility.

Today's prothrombin time for a client receiving warfarin 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Notify the health care provider immediately Assess for bleeding gums or IV sites Recognize that this is a therapeutic level Observe the client for hematoma development

Recognize that this is a therapeutic level For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually 1 1/2 to 2 times the normal levels.

A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication? Hyperglycemia Metabolic alkalosis Lowered basal metabolic rate Hypoxemia-Reduced partial pressure of oxygen in arterial blood (PaO2)

Reduced partial pressure of oxygen in arterial blood (PaO2) Hypothermia and cold stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).

A mother asks about expected motor skill development for her 3 year-old child. Which activity is considered a typical motor skill for the 3 year-old? Tying shoelaces Playing hopscotch Riding a tricycle Jumping rope

Riding a tricycle Three year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and are movement milestones for older children.

A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at this age? Loss of control Separation anxiety Bodily injury Fear of pain

Separation anxiety While a toddler will experience all of the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years.

The nurse assesses a full-term, 30 hour-old newborn and reviews its lab results. The nurse knows that the first-time mother is Rh negative and is breastfeeding exclusively. Which of these findings is a priority to report to the health care provider? Positive Coombs test Jaundice is observed Serum bilirubin of 11 mg/dL (188 mmol/L) Hematocrit 52%

Serum bilirubin of 11 mg/dL (188 mmol/L) Jaundice is a common condition in newborns. But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL (188 µmol/L) is high, which is why this is the priority finding to report to the health care provider. The concern about hyperbilirubinemia is increased because the mother is Rh negative (meaning there's a possible Rh incompatibility) and she is breastfeeding exclusively. The hematocrit is within normal limits for a newborn. The Coombs test results do not indicate if it's direct or indirect.

A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately? Venous blood pH 7.30 Serum potassium 6 mEq/L (6 mmol/L) Hemoglobin of 9.3 mg/dL (93 g/L) Blood urea nitrogen 50 mg/dL (17.9 mmol/L)

Serum potassium 6 mEq/L (6 mmol/L) Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (hemoglobin less than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women) is common with kidney disease. Blood urea nitrogen (BUN) will be increased in acute renal failure (7 to 30 mg/dL [2.5 to 10.7 mmol/L] is a considered normal).

The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect? Confusion Shallow respirations Tonic-clonic seizures Loss of half of visual field

Shallow respirations ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch.

A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention? She has been taking an ACE inhibitor for her blood pressure for the past two years. Her father and brother have type 1 diabetes She has taken 800 mcg of folic acid daily for the past year Her husband was treated for tuberculosis as a child

She has been taking an ACE inhibitor for her blood pressure for the past two years. A report by the client that she has been taking medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors, commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications and who are planning a pregnancy should be switched to medications that are not harmful to the developing fetus before they begin trying to get pregnant.

A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? Smoking cessation Stress management Physical exercise Weight reduction

Smoking cessation Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time.

A nurse is speaking at a community meeting about personal responsibility for health when a participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? Exercise of joints Spinal column manipulation Mind-body balance Electrical energy fields

Spinal column manipulation The theory underlying chiropractic treatment is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).

The client is prescribed dexamethasone by mouth every other day and asks the nurse for more information about the medication. What information would the nurse want to share with the client? (Select all that apply) Take the medication with food Do not get any immunizations or skin tests Mark your calendar to keep track of doses Take the medication at bedtime Avoid dairy products "You might experience an increase in weight"

Take the medication with food Mark your calendar to keep track of doses "Take acetaminophen for minor pain or aches." "You might experience an increase in weight" Adverse effects (ADEs) of long-term corticosteroid therapy include: behavioral/psychological changes, eye changes such as cataracts and glaucoma, and increased susceptibility to infections, hyperglycemia, hypocalcemia, fluid retention, HTN, edema, myopathy, muscle wasting, osteoporosis and peptic ulcers.To reduce the aforementioned ADEs, it is recommended to take the drug with food, avoid using NSAIDs for pain and increase dietary intake of calcium, found in dairy products.To prevent or avoid adrenal atrophy and acute adrenal insufficiency, discontinue corticosteroids gradually. Never discontinue corticosteroids abruptly!

Nursing students are reviewing the various types of oxygen delivery systems. Which oxygen delivery system is the most accurate? The Venturi mask A partial nonrebreather mask The simple face mask A nasal cannula

The Venturi mask The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. Correct!

The charge nurse has a health care team that consists of one licensed practical nurse (LPN), one unlicensed assistive personnel (UAP) and one LPN student. The charge nurse has made these assignments. Which assignment should be questioned by the nurse manager? Measuring vital signs and assisting with activities of daily living (ADLs) for the client admitted with myocardial infarction 4 days ago - UAP A client who was diagnosed with a major stroke 6 days ago - LPN student The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - LPN A child diagnosed with second-degree burns over 20% of the body, has IV packed red cells running and an order for IV albumin - charge nurse

The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - LPN LPNs can provide care for clients whose conditions are stable and there's a low likelihood of an emergency. Since it's a new admission, the client diagnosed with atrial fibrillation and heart failure should not be assigned to a student; the charge nurse (RN) should care for this client. A nurse can assign tasks or activities to UAP, as long as the care of the client is not too complex or variable and the client's condition is stable.

A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? The baby experienced distress during labor The baby is large for gestational age The baby is premature The baby is post-term

The baby is post-term Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower scores; higher scores correlate with post-maturity. Fetal distress during labor can result in lower scores.

An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. What should the nurse understand about the child's situation and administration of the immunization? Live vaccines are withheld in children with renal chronic illness The risk of the vaccine side effects precludes the administration of the vaccine An inactivated form of the vaccine can be given at any time The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant

The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system.

A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention? Tracheal deviation Tachypnea Tachycardia Increased restlessness

Tracheal deviation Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure.

A community health nurse is teaching a new parent group about primary prevention of lead poisoning in children. Which intervention should the nurse include? Use bottled water to add to any formula concentrate or powder. Monitor the child for developmental delays. Request chelation therapy from the child's pediatrician. Boil tap water for 10 minutes prior to adding to formula or food.

Use bottled water to add to any formula concentrate or powder. Lead exposure to children can result from multiple sources and can cause irreversible and life-long health effects. No safe blood lead level in children has been identified. Even low levels of lead in blood have been shown to affect IQ, ability to pay attention and academic achievement. Lead-contaminated water continues to pose a risk for many communities in the United States. Drinking water may become contaminated by lead from old lead pipes or the lead solder used in sealing the water pipes in older communities, building and homes. To reduce the risk of lead poisoning in infants in communities at risk for lead-contaminated water, a preventative intervention is to use bottled water to prepare formula from concentrate or powder. Boiling water will kill bacteria in water but does not remove the lead. Developmental delays are an outcome of lead poisoning, not a preventative measure. Chelation therapy is a treatment option for children diagnosed with high serum levels of lead; it is not a preventative treatment.

A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time? When the client's mood improves with an increase in energy level During the night shift when staffing is limited After a visit from the client's estranged partner At the time of the client's greatest despair

When the client's mood improves with an increase in energy level Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide. The clients have the energy to carry through with the plan for suicide.

A newly admitted 78 year-old client is diagnosed with severe dehydration. When planning care for this client, the nurse should assign which task to an unlicensed assistive personnel (UAP)? Converse with the client to determine if the mucous membranes are impaired Check skin turgor every four hours along with the need to change the adult diaper Monitor client's ability for movement in the bed from side to side Report hourly outputs of less than 30 mL/hr within 15 minutes of the check

eport hourly outputs of less than 30 mL/hr within 15 minutes of the check When assigning a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported and when. Because the RN is responsible for all care-related decisions, only routine tasks should be assigned to UAPs because such tasks do not require judgments and decisions.

The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best comment by the nurse should include which point? "Bones of children are more porous than adults' and often have incomplete breaks." "Compression of porous bones produces a buckle or torus type break." "A child's bone is more flexible and can be bent 45 degrees before breaking." "Bone fragments often remain attached by a periosteal hinge."

"Bones of children are more porous than adults' and often have incomplete breaks." This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side develops an incomplete fracture.

A client has just received an extracorporeal shock-wave lithotripsy (ESWL) procedure. What is the priority information the nurse should teach ? "Restrict milk and dairy products for one to two months." "Increase intake of citrus fruits to three servings per day for two months." "Limit fluid intake to 1,000 mL each day for two months." "Drink 3,000 to 4,000 mL of fluid each day for one month."

"Drink 3,000 to 4,000 mL of fluid each day for one month." Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi.

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and who becomes dyspneic. The nurse should take which action? Assist the client with pursed-lip breathing Place the client in a low Fowler's position Administer oxygen at six liters per minute via nasal cannula Instruct the client to breathe into a paper bag

Assist the client with pursed-lip breathing Pursed-lip breathing should be encouraged during periods of dyspnea in COPD to control rate and depth of respiration, to prevent alveolar collapse and to improve respiratory muscle coordination. Clients with COPD are usually on lower doses of oxygen, titrated to maintain an oxygen saturation of 88-91%. Semi-Fowler's position is usually most comfortable for someone with COPD, because this position allows the client's diaphragm to expand.

A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? Compromised host precautions Airborne precautions Contact precautions Droplet precautions

Contact precautions The resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required.