pretest

A client has just delivered an 8 lb 8 oz infant boy after a prolonged labor. The pediatrician prescribes ampicillin 50 mg to be given by the intramuscular route to the newborn every 8 hours. The nurse is initiating the first dose. Ampicillin is available in powder form for injection. The directions on the bottle indicate reconstitution with 0.9 mL of sterile diluent for a concentration of 125 mg/mL. How many milliliters (mL) should the nurse prepare to administer for the first dose? Fill in the blank. Record the answer to one decimal place.

answer: 0.4mL Rationale:Use the dosage calculation formula.Formula:Desired--------- × Volume = mLAvailable50 mg------ × 1 mL = 0.4 mL125 mg

A client presents to the urgent care center with a chemical burn of the right eye. The priority for the nurse is to prepare the client for which nursing intervention? 1.Application of a cold compress to the right eye 2.Application of a warm compress to the right eye 3.Minimizing movement of the right eye with a light bandage 4.Flushing the right eye with copious amounts of sterile solution

answer: 4 Rationale:When the client has suffered a chemical burn of the eye, the nurse immediately flushes the eye with a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water may be used. Applying compresses or bandages does not rid the eye of the damaging chemical. Warm compresses may be used for eye infections. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid.

The client has been prescribed nifedipine. The nurse is instructing the client about nifedipine. Which client statement indicates a need for further teaching? 1."I need to avoid alcohol and grapefruit juice." 2."My doctor will taper my dosage before stopping it." 3."I need to change my position slowly so I won't get dizzy." 4."If I see empty tab shells in my stool, I need to report it to my doctor."

answer: 4 rationale: Client teaching about nifedipine includes changing position slowly to avoid orthostatic hypotension and avoiding grapefruit juice and alcohol. The client is not to discontinue nifedipine abruptly but gradually taper dosage. If empty tab shells appear in stools, it is not significant.

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching? 1."I will give my child cough syrup if a cough develops." 2."During an attack, I will take my child to a cool location." 3."I can give acetaminophen if my child develops a fever." 4."I will be sure that my child drinks at least three to four glasses of fluids every day."

answer: 1 Rationale:Cough syrups and cold medicines are not to be given because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 mL to 1000 mL of fluids daily is important for thinning secretions.

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication? 1.Dementia 2.Schizophrenia 3.Seizure disorder 4.Obsessive-compulsive disorder

answer: 1 Rationale:Donepezil hydrochloride is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer's type. It enhances cholinergic functions by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease. This medication is not used to treat the disorders in options 2, 3, and 4.

The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client? 1."You need to avoid air travel." 2."It is all right to take a shower daily." 3."It is all right to begin your golf lessons." 4."You need to avoid bending activities for 1 week."

answer: 1 Rationale:Following ear surgery, clients need to avoid straining when having a bowel movement. Clients must be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients also must avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value? 1.20,000 mm3 2.100,000 mm3 3.120,000 mm3 4.150,000 mm3

answer: 1 Rationale:If a child is severely thrombocytopenic, with a platelet count of less than 20,000 mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000 mm3.

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate? 1.Bleeding 2.Infection 3.Renal colic 4.Normal, expected pain

answer: 1 Rationale:If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding. Signs of infection should not appear immediately after a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic.

A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar state (HHS) precipitated by acute illness. The client states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care understanding that which statement accurately reflects this client's level of knowledge? 1.The client needs immediate education before discharge. 2.The client requires follow-up teaching regarding the administration of insulin. 3.The client's statement is accurate, but knowledge should be evaluated further. 4.The client's statement is inaccurate, and the client should be scheduled for outpatient diabetic counseling.

answer: 1. Rationale:If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the primary health care provider should be notified. The client's statement in this question indicates a need for immediate education to prevent HHS, a life-threatening emergency situation.

The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1.Diarrhea 2.Heartburn 3.Flatulence 4.Constipation

answer: 2 Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called "heartburn" by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

A lethargic, yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam. During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for his age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem should have the highest priority? 1.Depressed sensorium 2.Altered respiratory status 3.Impaired sensory perception 4.Ineffective family processes

answer: 2 Rationale:Although all of the problems may be appropriate, airway is always the highest priority. The other problems can be addressed once a patent airway is ensured and maintained.

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom? 1.Dizziness after meals 2.Difficulty swallowing 3.Left lower quadrant pain 2 hours after eating 4.Moderate right upper quadrant pain unrelated to eating

answer: 2 Rationale:Although many clients with hiatal hernia are asymptomatic those with symptoms usually have difficulty swallowing, along with heartburn and reflux. Options 1, 3, and 4 are unrelated to this disorder.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure? 1.Eliminate between-meal snacks. 2.Drink decaffeinated coffee and tea. 3.Lie down for 30 minutes after eating. 4.Substitute salt in cooking for other spices.

answer: 2 Rationale:Caffeine, like spices, may cause heartburn and needs to be avoided. Spices tend to trigger heartburn. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.

A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure? 1.A stress test 2.A cesarean birth 3.Internal uterine contraction monitoring 4.Frequent repositioning from the right to the left side

answer: 2 Rationale:Early diagnosis of placental abruption is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood analysis, and either an immediate cesarean birth or vaginal delivery. Options 1, 3, and 4 are not helpful in managing this problem.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1.The client gives away a DVD and a cherished autographed picture of the performer. 2.The client runs out of the therapy group swearing at the group leader and then runs to their room. 3.The client gets angry with her roommate when the roommate borrows their clothes without asking. 4.The client becomes angry while speaking on their cell phone and slams the phone down on her bed.

answer: 1 Rationale:A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options 2, 3, and 4 identify acting-out behaviors.

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment? 1.Vital signs 2.Abdominal dressing 3.Urinary output in the Foley bag 4.Intravenous (IV) solution for accurate flow rate

answer: 1 Rationale:After observing the client has a patent airway, the nurse should check the client's vital signs. The vital signs will provide information regarding airway, breathing, and the circulatory status of the client. In addition, this information provides a baseline for further assessments. The abdominal dressing, IV, and urine output are also components of the assessment, and these assessments would follow the assessment of the vital signs.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? 1.Weight loss 2.Sleep pattern 3.Medication compliance 4.Onset of the crying spells

answer: 1 Rationale:All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 am. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 and is due to eat lunch at noon. List in order of priority the actions that the nurse should take. Arrange the actions in the order that they should be performed. All options must be used. -Take the client's vital signs. -Check the client's blood glucose level. -Give the client half a cup of fruit juice to drink. -Retest the client's blood glucose level. -Give the client a small snack of carbohydrate and protein. -Document the client's complaints, the actions taken, and the outcome.

answer: 1.Check the client's blood glucose level. 2.Give the client half a cup of fruit juice to drink. 3.Take the client's vital signs. 4.Retest the client's blood glucose level. 5.Give the client a small snack of carbohydrate and protein. 6.Document the client's complaints, the actions taken, and the outcome. rationale:The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first would check the client's blood glucose level to verify that the client is experiencing hypoglycemia. After this is verified, the nurse would give the client 10 to 15 g of carbohydrates and then retest the blood glucose level in 15 minutes. In the meantime, the nurse would check the client's vital signs. The nurse would give the client another food item containing 10 to 15 g of carbohydrate if the client's symptoms do not resolve. Otherwise, the nurse would provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than an hour away from the time of the occurrence. After treatment and the resolution of the hypoglycemic event, the nurse would document the occurrence, the actions taken, and the outcome.

The nurse is assigned to care for a client who has just returned to the nursing unit after having hemodialysis for the first time. The nurse monitors the client carefully for which signs and symptoms of disequilibrium syndrome? 1.Vomiting and headaches 2.Lethargy and hypertension 3.Hypertension and sleepiness 4.Abdominal pain and hypotension

answer: 1 Rationale:A complication that can occur during early dialysis is disequilibrium syndrome. This syndrome results from a high osmotic gradient in the brain following the rapid removal of fluid that can occur during hemodialysis. Because solutes are not removed as quickly from the cerebrospinal fluid (CSF) and brain, fluid from the circulation shifts into the brain causing cerebral edema. The client may exhibit nausea and vomiting, confusion, headaches, restlessness, twitching, muscle cramps, and seizures. Options 2, 3, and 4 do not identify signs of disequilibrium syndrome.

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action? 1.Administering oxygen via face mask 2.Placing the mother in a supine position 3.Increasing the rate of the intravenous (IV) oxytocin infusion 4.Documenting the findings and continuing to monitor the fetal patterns

answer: 1 Rationale:Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is decreased or discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions caused by the oxytocin. Documenting findings and continuing to monitor delay necessary treatment.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value? 1.2000 mm3 (2.0 × 109/L) 2.5800 mm3 (5.8 × 109/L) 3.8400 mm3 (6.4 × 109/L) 4.11,500 mm3 (11.5 × 109/L)

answer: 1 Rationale:The normal white blood cell count ranges from 5000 mm3 to 10,000 mm3 (5-10 × 109/L). The client who has a decrease in the number of circulating white blood cells is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility? 1.Report the case in which the abuse is suspected. 2.Refer the family to the appropriate support groups. 3.Assist the family in identifying resources and support systems. 4.Document the child's physical assessment findings accurately and thoroughly.

answer: 1 Rationale:The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case.

The nurse prepares to reinforce instructions to a client who is taking allopurinol. The nurse should include which instruction in the plan? 1.Instruct the client to drink 3000 mL of fluid per day. 2.Instruct the client to take the medication on an empty stomach. 3.Inform the client that the effect of the medication will occur immediately. 4.Instruct the client that if swelling of the lips occurs, this is a normal expected response.

answer: 1 rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. Allopurinol is an antigout medication used to decrease uric acid levels. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with or immediately following meals or milk to prevent gastrointestinal irritation. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the primary health care provider because this may indicate hypersensitivity.

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP? 1.Nausea 2.Papilledema 3.Decerebrate posturing 4.Alterations in pupil size

answer: 1 rationale: Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply. 1.Receiving assurance 2.Receiving information 3.Having support available 4.Remaining near the client 5.Talking to the doctor every day 6.Being given snacks to eat at the bedside

answer: 1, 2, 3, 4 Rationale:Needs of family members of critically ill clients are a very important concern for nurses working in critical care areas. Besides the basic need of comfort, family members need to receive information and assurance about the client's status. Family members also must be able to remain at the client's bedside and have support such as social service or religious ministry available, if needed. Being able to talk to the doctor every day may not be reasonable as long as the family members receive daily information. Also, having snacks at the bedside is not a basic family need.

The nurse has just received report on a newly admitted client who is cognitively impaired and experiencing pain. Which data collection techniques should be included in this client's plan? Select all that apply. 1.Observe for grimacing. 2.Listen for vocalizations. 3.Observe facial expressions. 4.Use a numerical pain scale. 5.Monitor for changes in behavior. 6.Use Wong-Baker Faces® pain rating scale.

answer: 1, 2, 3, 4, 5 Rationale:Assessing grimacing, vocalizations, behavioral changes, and facial expressions are all appropriate with a cognitively impaired client. A cognitively impaired client is likely unable to provide the nurse with a number rating of pain and will be unlikely to be able to understand and use the Wong-Baker scale.

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene? 1.The student uses wall suction unit pressure of 100 mm Hg. 2.The student suctions the client's tracheotomy tube for 15 seconds. 3.The student places the client in semi-Fowler's position before suctioning. 4.The student inserts the catheter into the tracheostomy without applying suction.

answer: 2 Rationale:Applying suction longer than 10 seconds can cause oxygen deprivation. The client should be placed into semi-Fowler's position to optimize breathing. Wall suction pressure of 100 mm Hg is usually recommended to prevent tissue disruption. The student is expected to insert the catheter without suction applied to maintain oxygen delivery and to prevent damage to the mucosa.

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 1.Listening to lung sounds 2.Obtaining the client's temperature 3.Checking the strength of peripheral pulses 4.Obtaining information about the client's respirations 5.Performing a musculoskeletal and neurological examination 6.Asking the client about a family history of any illness or disease

answer: 1, 2, 4 Rationale:A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1.Lengthening of umbilical cord 2.Sudden trickle or spurt of blood 3.Fundus is boggy following separation 4.Change from globular to discoid shape 5.Fetal membranes are seen at the introitus

answer: 1, 2, 5 Rationale:As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, a sudden trickle or spurt of blood appears and fetal membranes may appear at the introitus. The fundus changes from discoid to globular shape. The fundus should not become boggy.

The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the primary health care provider? Select all that apply. 1.Observe for bleeding. 2.Encourage the child to rest. 3.Aspirin 325 mg orally as needed for pain 4.Provide a hard toothbrush for mouth care. 5.Assist the registered nurse (RN) with blood transfusions.

answer: 1, 2, 5 rationale: The child with a platelet disorder is at risk for bleeding, so the nurse must observe for any bleeding problems. The child should be encouraged to rest to prevent falls and trauma. Also, packed red blood cells (RBCs) may be prescribed, so the licensed practical nurse must be ready to assist in the care of the child receiving the transfusion. Aspirin should not be given because it interferes with platelet function, and the child should use a soft toothbrush to minimize trauma to the mouth.

An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply. 1.Is it in the best interest of society? 2.Is it covered by the client's insurance? 3.Does its use violate the client's rights? 4.Is this therapy in the best interest of the client? 5.How many days before positive results are seen? 6.Has the client's family given permission for this therapy?

answer: 1, 3, 4 Rationale:Aversion therapy, also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties. Before beginning this therapy, the following questions must be answered by the therapist, treatment team, or society: (1) Is the therapy in the best interest of society? (2) Does it violate the client's rights? (3) Is it in the best interest of the client? The following questions are not related to beginning this therapy: (1) Is it covered by the client's insurance? (2) How long will it take for positive results? (3) Has the client's family given permission for this therapy? If aversion therapy is chosen as the most appropriate treatment, ongoing supervision, support, and evaluation of those administering it must occur.

The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply. 1.Denial 2.Confusion 3.Confabulation 4.Perseveration 5.Avoidance of questions 6.Repetition of phrases or behavior

answer: 1, 3, 4, 5 Rationale:Defense mechanisms related to the progression of Alzheimer's disease include denial, confabulation, perseveration, and avoidance of questions. Denial occurs fairly early in the disease process. Some people may have superior social graces and charm that give them the ability to hide severe deficits in memory, even from experienced health care professionals. Family members may also unconsciously deny that anything is wrong as a defense against the painful awareness that a loved one is deteriorating. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem. Perseveration is also called the repetition of phrases or behavior. This defense mechanism is eventually seen and is often intensified under stress. The avoidance of answering questions is another mechanism by which the person is able to maintain self-esteem unconsciously in the face of severe memory deficits. Confusion is not a defense mechanism.

A client with cancer is receiving cisplatin. Which findings indicate that the client is experiencing an adverse effect of the medication? Select all that apply. 1.Tinnitus 2.Increased appetite 3.Excessive urination 4.High-frequency hearing loss 5.Yellow halos in front of the eyes

answer: 1, 4 rationale: An adverse effect related to the administration of cisplatin, an antineoplastic medication, is ototoxicity with hearing loss. Tinnitus or ringing in the ears is associated with this ototoxicity. The nurse should monitor for this adverse effect when administering this medication. Increased appetite, frequent urination, and seeing yellow halos around objects are not adverse effects of this medication.

During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1.A fear of leaving the house 2.A fear of riding in elevators 3.A fear of speaking in public 4.A fear of uncleanliness and the need to bathe every hour

answer: 1. Rationale:Agoraphobia is a fear of open spaces (i.e., leaving the house); panic attacks may occur when doing so. Option 2 describes a fear of closed spaces (claustrophobia). Option 3 describes a fear of public speaking (social phobia). Option 4 describes an obsessive-compulsive behavior.

After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which signs/symptoms are indicative of this disorder? 1.Blurred vision and hot, dry skin 2.Excessive thirst and urine output 3.Diarrhea and decreased urine output 4.Weight gain and increased urine specific gravity

answer: 2 Rationale:Excessive thirst (polydipsia) and excessive urine output (polyuria) are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Diarrhea and blurred vision are not manifestations of the disorder. Weight gain and increased urine specific gravity are associated with syndrome of inappropriate antidiuretic hormone (SIADH).

The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention? 1.The medication is administered within 60 minutes before the morning and evening meal. 2.The medication is withheld and the PHCP is called to question the prescription for the client. 3.The client is monitored for gastrointestinal (GI) side effects after administration of the medication. 4.The insulin is withdrawn from the Penlet into an insulin syringe to prepare for administration.

answer: 2 Rationale:Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the PHCP regarding this prescription. Although options 1 and 3 are correct statements about the medication, in this situation it should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement? 1."Do you feel guilty about your child's weight gain?" 2."In most cases, medication and diet will control fluid retention." 3."Wearing loose-fitting clothing should help conceal the extra weight." 4."When children are little, it's expected that they'll look a little chubby."

answer: 2 Rationale:It is important to give the mother information that addresses the issue that is the parent's concern. Most children experience remission with treatment. Options 1 and 3 are nontherapeutic and may add to the mother's guilt. Option 4 does not acknowledge the concern and is a stereotypical response.

The nurse notes that a client is taking lansoprazole. On data collection the nurse should ask the client which question to determine medication effectiveness? 1."Has your appetite increased?" 2."Are you experiencing any heartburn?" 3."Do you have any problems with vision?" 4."Do you experience any leg pain when walking?"

answer: 2 Rationale:Lansoprazole is a gastric acid pump inhibitor used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD). It is not used to treat visual problems, problems with appetite, or leg pain.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? 1.A client with pneumonia 2.A client receiving diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtimes

answer: 2 Rationale:The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 1.Head midline 2.Head turned to the side 3.Neck in neutral position 4.Head of bed elevated 30 to 45 degrees

answer: 2 Rationale:The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response? 1."You're not a loser—you are just sick right now." 2."You don't think you can ever do anything right?" 3."Everything will get better—just you wait and see." 4."What makes you think you can't do anything right?"

answer: 2 Rationale:The statement in option 2, "You don't think you can ever do anything right?" allows the client to verbalize feelings. Option 2 also allows the nurse to learn more about what the client really means by the statement and also repeats the client statement. Option 1 may be threatening because, at this time, the client is not feeling that way. Option 3 places the client's feelings on hold, as does option 4, which is also inappropriate.

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

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

The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling? 1.Limit fluids. 2.Elevate the scrotum. 3.Apply heat to the abdomen. 4.Maintain a low-roughage diet.

answer: 2 rationale: Following herniorrhaphy, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The client also is instructed to apply a scrotal support when out of bed. Options 1, 3, and 4 are incorrect.

The nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. Which is the best nursing action? 1.Document the findings. 2.Notify the registered nurse (RN). 3.Recheck the vital signs in 1 hour. 4.Place the child in Trendelenburg's position.

answer: 2 rationale: In the event of bleeding and suspected shock, the primary health care provider is notified immediately. The nurse would contact the RN, who would then contact the primary health care provider. The child is never placed in Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. Rechecking the vital signs in 1 hour will delay necessary treatment. The nurse would document the findings, but the initial action would be to notify the RN to avoid any delays in treating this life-threatening situation.

The nurse has reinforced information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further teaching? 1."I should wait until my child is at least 24 months old." 2."I should have my child sit on the potty until my child urinates." 3."I know that my child will develop bowel control before bladder control." 4."I know my child is ready to begin toilet training if my child can walk well."

answer: 2 rationale: The mother should wait until the child is 24 to 30 months old because this makes the task of toilet training considerably easier. Toddlers of this age are less negative and usually are more willing to control their sphincters to please their parents. Bowel control is usually achieved before bladder control. The child should not be forced to sit on the potty for long periods. The ability to sit, squat, and walk well are physical signs of readiness.

The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply. 1.Sleeps well through the night 2.Shows a lack of interest in eating 3.Lacks the ability to concentrate on tasks 4.Complains of feeling tired all of the time 5.Shows enthusiasm to care for her newborn

answer: 2, 3, 4 Rationale:Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.

A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions should be employed for the newborn to decrease the risk of HIV. Select all that apply. 1.Encouraging breastfeeding 2.HIV testing of the newborn within 48 hours 3.Isolation of the infant with airborne precautions. 4.Antiretroviral prophylaxis for newborns testing HIV positive. 5.Periodic testing for HIV at set intervals until the age of 6 months.

answer: 2, 4, 5 Rationale:There are known methods to decrease the risk of transmission of HIV from a positive mother to the infant including caesarian section delivery and treatment of the mother with antiretroviral medications. A newborn of a mother who is HIV positive should be tested within 48 hours of delivery and then at set intervals until the age of 6 months. The infant may test positive due to transmission of maternal antibodies and not be truly HIV positive. Antiretroviral prophylaxis for newborns testing HIV positive is started and continues for 6 weeks. Breastfeeding is not recommended for the HIV positive mother. Airborne precautions are not indicated for the newborn.

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity? 1.Giving the client nectar-thickened coffee 2.Placing food on the affected side of the mouth 3.Allowing ample time for chewing and swallowing 4.Giving foods and fluids with the consistency of oatmeal

answer: 2. rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned and a consultation with the speech therapist and dietician is done and a prescription for the diet modifications is completed. Liquids should be thickened to the consistency of oatmeal to avoid aspiration. Food is placed on the unaffected side of the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.

The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning? 1.Client skin color (pink) 2.Breath sounds are clear 3.Client statement of comfort 4.Sao2 is 98% by pulse oximetry

answer: 2. rationale: The nurse evaluates the effectiveness of the suctioning procedure by auscultating breath sounds. This helps determine if the respiratory tract is clear of secretions. In addition, breath sounds must be auscultated before every suctioning procedure. Options 1, 3, and 4 do not determine the effectiveness of suctioning.

A client with pneumonia is admitted to the hospital, and the primary health care provider writes prescriptions for the client. Which prescription should the nurse complete first? 1.Increase the intake of oral fluids. 2.Administer a prescribed antibiotic. 3.Obtain a culture and sensitivity of sputum. 4.Encourage the use of an incentive spirometer.

answer: 3 Rationale:A culture and sensitivity should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. Options 1, 2, and 4 are standard parts of therapy for pneumonia, but sputum is collected first.

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study should assist in confirming the diagnosis of RF? 1.Immunoglobulin 2.Red blood cell count 3.Antistreptolysin O titer 4.White blood cell count

answer: 3 Rationale:A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 4 will not assist in confirming the diagnosis of RF.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? 1.Request that a peer remain with the client at all times. 2.Remove the client's clothing and place the client in a hospital gown. 3.Assign a staff member to the client who will remain with him or her at all times. 4.Admit the client to a seclusion room where all potentially dangerous articles are removed

answer: 3 Rationale:Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1.A staff member who has never had roseola 2.A staff member who has never had mumps 3.An unlicensed assistive personnel who has never had chickenpox 4.An unlicensed assistive personnel who has never had German measles

answer: 3 Rationale:Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox. Options 1, 2, and 4 are not associated with the herpes zoster virus

The client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1.Constipation 2.Abdominal pain 3.An episode of diarrhea 4.Hematest-positive nasogastric tube drainage

answer: 3 Rationale:Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.

The nurse realizes that the client taking metformin needs further teaching when the client makes which statement? 1."Metformin may cause flatulence and diarrhea." 2."Metformin will help decrease the glucose production by my liver." 3."I should treat hypoglycemic episodes due to metformin with glucose tablets only." 4."I should not take my metformin for 48 hours after certain diagnostic tests that use dye."

answer: 3 Rationale:Metformin may be used alone or with other medications, including insulin, to treat type 2 diabetes. Metformin is in a class of drugs called biguanides. Metformin helps control the amount of glucose in your blood. It decreases the amount of glucose absorbed from food and the amount of glucose made by the liver. Metformin also increases the body's response to insulin, a natural substance that controls the amount of glucose in the blood. Gastrointestinal side effects such as flatulence and diarrhea can occur from this medication. Lactic acidosis can occur from the interaction of contrast dye and metformin; therefore, as prescribed, metformin is withheld for 48 hours after certain diagnostic tests that use dye.

The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs? 1.Bleeding 2.Failure to thrive 3.Heart failure (HF) 4.Decreased tolerance to stimulation

answer: 3 Rationale:Nursing care for Kawasaki disease initially centers on observing for signs of HF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, lung congestion, and abdominal distention. Options 1, 2, and 4 are not findings directly associated with this disorder.

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse? 1."Why do you believe this?" 2."Tell me more about the details of your belief." 3."I hear what you are saying, but I don't share your belief." 4."If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute."

answer: 3 Rationale:Paranoid beliefs are coping mechanisms and therefore not easily relinquished. It is important not to support the belief and not ridicule, argue, or criticize it. Asking the client "why" places the client in a defensive position. Encouraging the client to expound on the belief when discussion would be limited is also inappropriate. Threatening the client by denying a privilege is unethical.

The nurse determines that which client is most likely to be a candidate for cardioversion? 1.Client with junctional rhythm 2.Client with ventricular fibrillation 3.Client with unstable rapid atrial fibrillation 4.Client with pulseless ventricular tachycardia

answer: 3 rationale: Cardioversion is a synchronized shock, delivered during ventricular depolarization. The machine must be able to seek out R waves and mark them so that the device delivers the shock at the appropriate time. Clients in atrial fibrillation are candidates for this treatment, and the goal is to try to restore normal sinus rhythm through cardioversion. Although the client with ventricular tachycardia can be cardioverted because of the presence of QRS complexes, this is done only when the client has a pulse. Pulseless ventricular tachycardia and ventricular fibrillation clients always are defibrillated. Junctional rhythm is neither cardioverted nor defibrillated.

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1.Dehydration 2.Heart failure 3.Iron deficiency anemia 4.Chronic obstructive pulmonary disease

answer: 3 rationale: The normal hemoglobin level for an adult female client is 12 g/dL to 16 g/dL (120-160 g/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater? 1.A space heater should not be used in an apartment. 2.The space heater should always be kept at a low setting. 3.The space heater should be placed in the hallway at nighttime. 4.The space heater needs to be placed at least 3 feet from anything that can burn.

answer: 4 Rationale:Space heaters need to be used appropriately because they present a great risk of fire. A space heater needs to be placed at least 3 feet from anything that can burn. Placing a heater in a hallway does not guarantee that it will be 3 feet from anything that can burn. A low setting does not reduce the risk of fire. A space heater can be used in an apartment if there is ample space and safety precautions are followed

A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) should the nurse occlude? 1.Ulnar artery and observes for color changes in the affected hand 2.Radial artery and observes for color changes in the affected hand 3.Brachial and radial arteries, then releases both and observes the circulation to the hand 4.Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

answer: 4 Rationale:Before drawing an ABG, the nurse checks the collateral circulation to the hand with the Allen's test. This involves compressing both the radial and ulnar arteries and asking the client to close and open the fist. This should cause the hand to become pale. The nurse then releases pressure on one artery and observes if circulation is quickly restored. The process is then repeated releasing the other artery. The blood sample may be safely taken if there is adequate collateral circulation. Only the radial and ulnar arteries are occluded; the brachial artery would not be occluded when performing the Allen's test.

The nurse assisting in caring for a client with a myocardial infarction is monitoring for cardiogenic shock. The nurse should monitor for which peripheral vascular symptoms? 1.Flushed, dry skin with bounding pedal pulses 2.Warm, moist skin with irregular pedal pulses 3.Cool, dry skin with alternating weak and strong pedal pulses 4.Cool, clammy skin with either weak or thready pedal pulses

answer: 4 Rationale:Classic signs of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreased urine output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin.

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the newborn's plan of care? 1.Delay feeding the newborn for 4 hours. 2.Maintain routine vital signs assessment. 3.Promote early maternal newborn interaction. 4.Observe vital signs and central nervous system status frequently during the first 2 days.

answer: 4 Rationale:Clinical signs of sepsis in the newborn include temperature instability, tachycardia, respiratory changes, and central nervous symptoms such as lethargy or irritability. If sepsis is a risk, the nurse should monitor vital signs and central nervous system status frequently. Promoting early maternal-newborn interaction is always important but is unrelated to this question. Delaying a feeding is not appropriate.

The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication? 1.Checking the quality of the radial pulse 2.Checking the child's ability to extend the fingers 3.Checking for effectiveness of analgesics administered for pain 4.Checking the child's ability to perform range of motion to the shoulder area of the affected extremity

answer: 4 Rationale:Compartment syndrome occurs when swelling causes pressure to rise within a compartment (sheath of inelastic fascia). The increased pressure compromises circulation to the muscles and nerves within the compartment and can result in paralysis and necrosis of tissues. Signs of compartment syndrome include severe pain, often unrelieved by analgesics, and signs of neurovascular impairment. Compartment syndrome is not uncommon in fractures of the forearms; therefore, the quality of the radial pulse and the ability to extend the fingers should be assessed. If extension of the fingers produces pain, the primary health care provider should be notified. Option 4 is unlikely to provide information about compartment syndrome.

The nurse is providing instructions to a client beginning medication therapy with divalproex sodium for the treatment of absence seizures. The nurse instructs the client that which is the most frequent side effect of this medication? 1.Tinnitus 2.Irritability 3.Blurry vision 4.Nausea and vomiting

answer: 4 Rationale:Divalproex sodium is an anticonvulsant. The most frequent side effects of medication therapy are gastrointestinal (GI) disturbances such as nausea, vomiting, and indigestion. The items in the other options are not side effects.

The licensed practical nurse (LPN) is obtaining a client's signature on an informed consent for a total knee replacement surgery. The client has many questions and seems reluctant to sign the consent. Which best action should the LPN take? 1.Ask the registered nurse to explain the procedure. 2.Notify the supervisor that the client has not signed the form. 3.Explain the procedure in detail answering the client's questions. 4.Notify the surgeon that the client has many questions about the procedure.

answer: 4 Rationale:For the client to have sufficient information for informed consent, the person must have been advised of risks, benefits, alternatives, and consequences of refusing the treatment. A client has the right to have all questions answered. The primary health care provider is responsible for obtaining informed consent. Nurses may obtain client signatures and serve as witnesses to the signature as agency policy permits. The nurse should ask the client if he or she understands the procedure. If the nurse suspects the client lacks decision-making capacity or does not fully understand the implications of the consent form, the primary health care provider should be contacted. The supervisor can be notified about the situation.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action? 1.Leave the leg padding in the device. 2.Use the "stop-go" button found on the machine. 3.Keep the knee aligned with the hinged joint on the machine. 4.Reset the degrees of flexion or extension according to comfort.

answer: 4 Rationale:Some surgeons prescribe CPM postoperatively for clients undergoing total knee replacement. The purpose of CPM is to increase the joint range of motion. The client is instructed to stop and start the continuous passive motion device and leave the padding in the device for leg protection. The client should be taught proper positioning and alignment. The client should not try to adjust the flexion and extension settings. These are decided on by the orthopedic surgeon and are maintained as prescribed.

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs? 1.Fatigue 2.Nausea 3.Headache 4.Backache

answer: 4 Rationale:The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include a backache among other signs such as chills, itching, or rash. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue, headache, and nausea are not specifically related to transfusion reaction; however, if these occur, the nurse should investigate their cause.

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

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

Fluoxetine hydrochloride is prescribed for a client being treated for depression, and the nurse reinforces instructions to the client regarding the medication. Which statement by the client would indicate that the client understands this medication therapy? 1."If my mouth becomes dry, I need to stop the medication." 2."If I don't feel better in 1 week, I need to stop the medication." 3."I will need a stronger dose if I don't feel results in a few days." 4."It takes approximately 2 to 4 weeks before improvement is noted."

answer: 4 Rationale:The time frame in which the therapeutic effects of fluoxetine hydrochloride are seen is usually 2 to 4 weeks after initiation of therapy. It is important to advise clients to comply with the prescribed regimen so that therapeutic levels are maintained. Dry mouth is a side effect of the medication, and the client would be instructed to relieve the dry mouth by chewing sugarless gum or sipping tepid water.

The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia? 1."Blurred vision is not a normal occurrence." 2."I will report any appearance of facial edema." 3."I will be alert to any change in fetal movements." 4."I should expect that my urine output will decrease."

answer: 4 Rationale:Warning signs and symptoms of progression of preeclampsia to be reported include decreased urinary output; headaches and blurred vision; abdominal pain; and a change in fetal movement, particularly a decrease. Facial edema should be reported because the preeclampsia could be worsening.

A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question? 1.Restrict fluid intake. 2.Insert an indwelling urinary catheter. 3.Keep an intravenous (IV) line patent. 4.Suction via the nasotracheal route as needed.

answer: 4 rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of I&O. An IV line is maintained to administer fluids or medications, if necessary.

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1."I can give my child acetaminophen for fever." 2."I will watch for any hearing loss that may occur." 3."I know that I will need to watch for any rash that my child may develop." 4."I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

answer: 4 rationale: Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis. Options 1, 2, and 3 are correct.

The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location should the nurse select to administer the medication? 1.Deltoid muscle 2.Dorsogluteal muscle 3.Ventrogluteal muscle 4.Vastus lateralis muscle

answer: 4 rationale: The vastus lateralis muscle is the best choice for all age groups and should always be used in children younger than 3 years of age. The ventrogluteal muscle is safe for children older than 18 months because it is free of major blood vessels and nerves. The dorsogluteal muscle develops with walking, so it should not be used until the child has been walking for at least 1 year. The dorsogluteal site is not recommended at any age because of the proximity of the sciatic nerve. The deltoid muscle is not used for children because the small muscle mass cannot hold large volumes of medication or medications that must be injected deep into the muscle mass.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor the skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with shields or patches.

answer: 4, 5, 6 Rationale:Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.