Quizzes 31-40

A nurse assigned to a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis on the plan of care is a priority at this time?

Ineffective breathing patterns related to central nervous system depression Respiratory depression is a life-threatening risk in narcotic overdoses.

The nurse prepares to perform tracheal suctioning on a client who is a paraplegic. What is the reason for placing the client in a high-Fowler's position prior to suctioning?

Maximize expansion of the client's lungs High or semi-Fowler's positions maximize lung expansion and allows for effective coughing to help facilitate the removal of lung secretions during the suctioning process.

The 54 year old client is scheduled for a coronary angiography. The client's medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate?

Monitor serum creatinine levels pre- and post-procedure Coronary angiography requires the use of a contrast dye. Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN). Adequate hydration helps maintain renal blood flow and reduces the time the contrast media is in contact with the renal tubules and, therefore, will help prevent CIN. Serum creatinine levels are used to monitor for the development of CIN. Nephrotoxic drugs, such as ibuprofen, should not be used for procedures requiring contrast media. The oral hypoglycemic drug metformin increases the risk of lactic acidosis if CIN were to occur; it should be held the day of the procedure until kidney function returns to baseline (as determined by serum creatinine).

The nurse is discussing with a new mother the proper techniques for breastfeeding an infant. Which statement made by the mother indicates incorrect information and the need for additional instruction?

"I will give the baby a pacifier in between nursing."

The nurse is discussing with a new mother the proper techniques for breastfeeding an infant. Which statement made by the mother indicates incorrect information and the need for additional instruction?

"I will give the baby a pacifier in between nursing." Babies adapt more quickly to the breast when they aren't confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. You should realize that when you are asked to identify a statement that needs more teaching, the correct response will actually be an incorrect statement. To help answer this type of question you can treat each of the statements as a true/false statement. The statement you identify as being "false" is the correct response.

While obtaining the history of a 2 week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24 hours-old. Which action should the nurse take?

Obtain a repeat blood test at this point Testing for PKU is most reliable when protein has been ingested for at least 24 to 48 hours. A repeat blood specimen must be obtained by the third week of life if the initial specimen was taken from an infant less than 24 hours-old.

A 9 year-old child is taken to the emergency department with right lower quadrant pain and vomiting. During preparation of the child for emergency surgery, the nurse should know that the child's greatest fear would be related to what issue?

Perceived loss of control For school-age children, 6 to 12 years of age, major fears are associated with loss of control and separation from friends/peers. Although the child would most likely be afraid of the unfamiliar environment, the greatest concern would be the loss of control.

A client is admitted directly from surgery in skeletal traction for a fractured femur. Which of these nursing interventions should be the priority?

Perform frequent neurovascular assessments of the affected leg The priority postoperative action is to assess the neurovascular status of the leg after a fracture. Nursing management of a client in skeletal traction also includes assessing and caring for pin sites, and educating the client and family about skeletal traction. The overhead trapeze helps the client move in bed and proper body alignment is important, but these are not the priority.

A client is unconscious after a tonic-clonic seizure. What should the nurse do at this time?

Place the client in a side-lying position Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. Nothing should be placed in the client's mouth. The other actions are appropriate, but are not the highest priority at this time. Remember that when a safety option is available, it may be the correct answer (especially when there isn't an urgent physiologic need).

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.)

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, and not just palpate the abdomen, 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 nurse is caring for a post-surgical client at risk for the development of deep vein thrombosis (DVT). Which action is preventative and should be reinforced by the nurse?

ROM, exercise, and walk Mobility reduces the risk of DVT in the post-surgical client and in any adults at risk. Clients should perform ROM exercises of the legs while in bed, and they should get out of bed to stand, sit in a chair or walk in the hallway several times a day. It is contraindicated to place pillows under the knees because pillows will press against the veins and cause an increase in venous stasis. Antiplatelet agents are not the drug of choice for DVT prevention. Leg massage should be avoided as it can dislodge a thrombus causing pulmonary embolism, which is a very serious complication of DVT.

The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program?

Reduce readmissions to the hospital Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.

The licensed practical nurse (LPN) is caring for a client diagnosed with chronic obstructive lung disease (COPD). Which of these findings should the (LPN) immediately report to the registered nurse (RN)?

restlessness and confusion Respiratory failure may be signaled initially by restlessness, and then by confusion, central cyanosis, excessive somnolence and shortness of breath. When these findings occur, a pulse oximetry reading (or ABGs) should be obtained. Central cyanosis is cyanosis of the mucous membranes as opposed to peripheral cyanosis, which is cyanosis of the extremities. If you are not sure about the correct response, you can eliminate the option with a GI focus because the question relates to a respiratory issue. Pursed-lip breathing is an expected finding with COPD and does not need to be reported immediately to the RN. Finally, fever and cough can have many different causes. When someone is restless or confused, one of your first thoughts should be hypoxia and this should be considered a priority.

When taking the client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first?

wait two minutes and do bp in the same arm - between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two-minute wait and it may not provide a reading for a very low pressure. The nurse should have palpated the brachial artery first, before applying the cuff.

While assisting with the discharge of a child, the LPN is reinforcing information about phenytoin with the child and the child's parents. Which statement made by the parents is incorrect and indicates a need for further information?

"It is okay to change brands of medication to help control cost." Remember that with these types of questions, three of the responses are correct statements. You will select the statement with incorrect information. Although generic drugs are usually as safe and effective as the brand name version, this is not the case for phenytoin. Switching to a generic form of this drug may result in a change in dose that will be ineffective or cause side effects in the child. Some people have even reported "breakthrough" seizures when switching from a brand to generic version of a seizure drug or even between different generics made by different manufacturers.

The nurse is discussing accident prevention with parents. Which child would be at the highest risk for accidental poisoning?

20 month-old who has just learned to climb stairs Toddlers are at the highest risk for poisoning because they are increasingly mobile, need to explore, and engage in autonomous behavior. Learning to climb stairs enhances the chance of them to climb onto chairs and countertops to get access to poisonous substances. Toddlers continue to explore the world through their mouths. To answer this question, use some common sense to eliminate three options: a 9 month-old is minimally mobile, the 10 year-old understands rules, and the 15 year-old working on bicycles is not exposed to poisoning.

The nurse checks lab results for an adult client with suspected cancer prior to a liver biopsy. Which finding requires immediate notification of the health care provider?

Activated partial thromboplastin time (aPTT) of 50 seconds Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding is one of the risks. An elevated aPTT increases the risk of bleeding. Abnormal findings in the other labs would not increase the client's risk of complications following a liver biopsy.

A client has been receiving heparin for five days and now has an order to begin taking warfarin in the evening. Which intervention should the nurse take next?

Administer the warfarin in the evening as prescribed Warfarin takes two to three days before its anticoagulant effect begins to peak at a therapeutic level. Therefore, the heparin is continued until that point. The prothrombin time (PT) or international normalized ratio (INR) is used to monitor the effectiveness of warfarin therapy and heparin will be monitored daily using the activated partial thromboplastin time (aPTT) lab test.

A nurse is reinforcing information about actions to prevent hypercalcemia to a client diagnosed with metastatic bone disease. Which topic is important for the nurse to discuss with the client?

Ambulation Ambulation promotes mineralization of bones and can reduce serum calcium levels. During reinforcement of client teaching, it is preferred that the interventions that are most client-focused and least invasive be emphasized first. Volume expansion, hemodialysis and diuretics can also all decrease serum calcium levels. If you are unsure of the correct response, you should note that three of the options involve medical, and not nursing, interventions. Ambulation is the only client-centered and nursing response.

The nurse is reinforcing discharge teaching to a client with asthma. During the discussion, a warning should be given about the use of which over-the-counter medication?

Aspirin products for pain Aspirin is known to induce asthma attacks and can also cause nasal polyps and rhinitis. Notice that two of the (incorrect) options are respiratory answers; these are the distractors. Now, left with two responses, you should ask yourself if an ointment or an oral medication creates a systemic response.

A client is prescribed atenolol. The nurse should emphasize to the client to immediately report which finding?

Atenolol (Tenormin) is a beta blocker. Side effects of this medication include bradycardia and hypotension. Beta blockers should be used cautiously in clients diagnosed with asthma because they may stimulate bronchospasm as a side effect. The spelling of the generic name of beta blockers often end with "lol."

There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take?

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 client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities that have which effect?

Can cause dehydration The client must take in adequate fluids before and during exercise periods to prevent dehydration. Dehydration stresses the body, which can contribute to MS symptoms. An increase in heart rate is normal during exercise. Exercise is naturally aerobic. Competitive exercise such as tennis is not contraindicated as long as the client does not become dehydrated. The correct option is the only answer that would not be a benefit of regular exercise.

The nurse is caring for a child diagnosed with Reye's syndrome. The nurse should give which of these interventions the highest priority?

Check level of consciousness Decreased level of consciousness suggests increased intracranial pressure related to cerebral edema and encephalopathy.

A male client with benign prostatic hypertrophy is admitted with a distended bladder due to acute urinary retention. There is an order to insert an indwelling urinary catheter (IUC). What should the nurse understand about catheter insertion and care for this client?

Empty the bladder quickly and completely With acute urinary retention, treatment begins with catheterization. It's best to use the smallest catheter size (14 to 16 Fr); a coude-tipped catheter is often used in men with an enlarged prostate or urethral stricture. Evidence-based practice supports complete and rapid emptying of the bladder. The client may need to have an IUC for several days. Bladder irrigation is performed to maintain patency of a retention catheter by removing sediment or clots, usually following a surgical procedure involving the urinary system.

The nurse is providing care for an 18 month-old toddler. What information should be used when assisting with developing the care plan for this child?

Encourage the child to eat finger foods According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living, especially feeding and dressing self. It is unsafe to allow the toddler to walk on the unit. Holding and cuddling is more appropriate for infants. Playing games with other children would be associated with the developmental stage of the school-aged child.

A client who received chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which nursing intervention should receive priority?

Inspect all sites that may serve as entry ports for bacteria Prompt recognition of the source of infection and subsequent initiation of therapy will reduce morbidity and mortality in sepsis. This should be the nurse's first action. Central line infections are common causes of sepsis that can be avoided through appropriate central line care. Pay attention to the word "priority" and remember that gathering data comes before any other action.

The nurse is participating in the plan of care for a school-aged child diagnosed with a vasoocclusive crisis of the elbow. Which intervention should be selected as the priority?

Monitor the patient controlled analgesia (PCA) Vasoocclusive crisis involves severe pain due to infarctions. It is an acute condition seen in sickle cell anemia. Management of a crisis is directed towards supportive and symptomatic treatment; the priority of care is pain relief. In a school-aged child, patient controlled analgesia (PCA) promotes maximum comfort. Oxygenation and hydration would be the next focuses.

A client is diagnosed with confusion and anemia. While caring for this client, which task should the practical nurse assign to an unlicensed assistive person (UAP)?

Test stool for occult blood The UAP can do standard, unchanging tasks with predictable outcomes, like obtaining and testing stool for occult blood. The nursing functions of assessment, planning, evaluation and nursing judgment cannot be delegated.

During the two-month well-baby visit, the mother explains that baby formula seems to stick to her baby's mouth and tongue. Which action by a nurse would provide the most valuable information?

Use a soft cloth to attempt to remove the patches Candidiasis can be distinguished from coagulated milk by trying to wipe the patches from the mouth and tongue. When attempts to remove the patches with a soft cloth are unsuccessful or the tongue bleeds, then candidiasis infection is suspected. Also known as oral thrush, this common infection is caused by the overgrowth of the yeast Candida albicans.

A nurse is discussing negativism with the parents of a toddler. The nurse should tell the parents that their best response to this behavior would be which action?

Use patience and a sense of humor to deal with this behavior The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle this by using patience and humor. Toddlers say "no" because they can, not because they are trying to be difficult or mean. Although limit-setting and consistent boundaries for behavior is important for toddlers, asserting authority or punishment for saying "no" is not what is indicated.

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Postoperatively the client is reports having chest tightness. The peak flow is now 200 liters/minute. What should the nurse do first?

Administer the PRN dose of albuterol Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma. This will help determine the severity of the exacerbation and guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta-agonist (such as albuterol) should be taken immediately.

A client, diagnosed with active tuberculosis (TB), has a history of medication noncompliance. Which action by the nurse indicates an understanding of the appropriate care needed for this client?

Ask a family member to supervise daily medication compliance Direct-observed therapy is a recognized method for ensuring client compliance to any medication regimen. The program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location. Notice the word "compliance" the correct option, which matches the content in the question. Remember that contacting a health care provider would not normally be considered a correct option unless the information in the question is life-threatening, potentially life-threatening, or if a health care provider's order is needed.

A client has an order for 1000 mL of D5W to run over an eight-hour period. The nurse discovers that 800 mL has been infused after only four hours. What is the priority nursing action at this time?

Auscultate lungs All of the options are correct actions and would be part of the treatment plan following too rapid administration of a large amount of fluid. However, the most serious consequence could be heart failure with lung congestion, which makes auscultation of the lungs the priority action. The sequence of actions would be: auscultate the lungs, ask the client about breathing problems, check vital signs, encourage the client to void as much/as often as possible, and then notify the charge nurse.

A nurse is preparing to perform parts of a physical examination on an 8 month-old infant who is sitting contentedly on the mother's lap. Which action should the nurse perform first?

Auscultate the lung sounds The nurse should auscultate the lung sounds during the first quiet moment with the infant in order to hear the sounds clearly. Other actions may follow in any order.

A client has developed a deep venous thrombosis (DVT) of the left leg. Which intervention on the plan of care should be given the highest priority?

Elevate leg on two pillows The first goal of non-pharmacologic interventions in DVT is to minimize edema and venous stasis of the affected extremity by leg elevation. Support stockings are used for prevention of venous thrombosis, not treatment. Clients may be able to go to the bathroom or use a bedside commode, but this is not the highest priority. Warm compresses will enhance arterial circulation to the site and provide comfort, but the problem is with venous circulation.

The client is diagnosed with Addison's disease. What should the nurse understand about the diet of a person with this diagnosis?

Increase sodium and drink at least 1.5 liters of water each day In Addison's disease, the adrenal glands do not make enough of the hormone cortisol (and sometimes aldosterone). This results in sodium wasting and potassium retention. The findings are typically dehydration, hypotension, hyponatremia, hyperkalemia and acidosis. Mineralocorticoids are usually the preferred treatment. Also, fluids and dietary sodium intake should be increased; potassium intake should be restricted. Don't confuse this with Cushing's disease in which sodium intake is restricted. Eating just enough calories to maintain a healthy weight is too generic a statement for Addison's disease.

The charge nurse is making client room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3 year-old child diagnosed with minimal change disease?

4 year-old with bilateral inguinal hernia repair Minimal change disease is a kidney disorder that can lead to nephrotic syndrome. Corticosteroids can cure the disease in most children but cytotoxic therapy and other drugs may be needed, but this treatment can reduce the child's ability to fight infection. The charge nurse must select a roommate who does not have an infection, which is the child who just had surgery. The sickle cell crisis may have been triggered by an infection. The child who's sibling has a viral disease has the potential to develop an infection.

The nurse is reinforcing information to a 10 year-old child who will be undergoing heart surgery. Which approach would be best for the nurse to use?

A model of the heart to explain the surgery According to Piaget, the school-age child is in the concrete operations stage of cognitive development. Using something concrete, like a model, will help the child understand the explanation of the heart surgery.

A health care provider orders digoxin 0.125 mg and furosemide 40 mg by mouth every day. The nurse would recommend the client should eat which of these foods on a daily basis?

A slice of watermelon is the highest in potassium and will replace any potassium lost by the diuretic. A tomato has high potassium but not as much as a slice of watermelon. The other foods do not have high levels of potassium.

The parents of a 7 year-old client tell the nurse their child has started to "tattle" on siblings. The nurse should respond with the knowledge that children of this age group act in this manner for what reason?

An ethical sense and feelings of justice are expected developmental processes The child is developing a sense of justice and a desire to do what is right. At 7 years old, children are increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment.

The client is an asthmatic who has recently developed gastroesophageal reflux disease (GERD). Which prescribed medication may aggravate GERD?

Anticholinergics An anticholinergic medication will decrease gastric emptying by decreasing peristalsis. It also relaxes the lower esophageal sphincter, which allows acid to "reflux" into the esophagus. Because the content of this question is GERD, and not asthma, corticosteroids and histamine blockers can be eliminated right away. There is nothing in the question that would indicate the need for an antibiotic.

A nurse is participating in a community health fair. As part of the health promotion process, when should the nurse conduct a mental status examination?

Anytime health screening is done A mental status check is a critical part of baseline information and should be a part of every examination, whether general or specific. You will notice that three of the options indicate a problem with mental status; however, this is a "health promotion" question. Associate the word "health" in the correct option with the question. Additionally, this is a general question and the only general option is the correct option.

A 75 year-old Catholic Latino client with prostate cancer adamantly refuses pain medication because of the belief that "suffering is part of life" and that life is in God's hands. What action should the nurse take in response to this situation?

Ask if the client would like to speak with a priest Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework. Associate the option using the word "priest" with the words in the stem of the question (Catholic and in God's hand). Also note that this is the only response that is most directly associated with the problem - life.

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 client with 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 expan

A client diagnosed with bipolar disorder has been taking lithium (Eskalith, Lithobid) for the past two weeks. During a regularly scheduled appointment, what information should the nurse reinforce with the client?

Have serum lithium levels drawn more frequently during the summer months When lithium is first prescribed, there are frequent blood tests to measure and monitor the amount of lithium in the blood. But once the therapeutic range has been achieved, then lithium can be monitored at regular intervals (and not necessarily every one to three months). Clients taking lithium need to be aware that hot weather may cause excessive perspiration, a loss of sodium, and consequently an increase in serum lithium concentration. As a result, more frequent blood tests may be indicated during the summer months. Lithium should be taken with food, and the client should not change or reduce intake of sodium when taking lithium.

A hospitalized infant receives digoxin to treat cardiac problems. Prior to administering the next dose of medication, the infant's parent reports that the baby has vomited once, just after the morning feeding. The heart rate is 94. What should be the initial response by the nurse?

Hold the medication Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting, poor feeding, dizziness, headache, weakness and fatigue. In infants and young children, only one episode of vomiting, associated with mealtime, does not usually warrant withholding the medication. However, bradycardia (normal rate in this age child is 120 - 160 BPM in the awake stage) is sufficient reason to hold the medication and notify the health care provider.

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which intervention would be most appropriate?

Inspect the nares and ears for skin breakdown Oxygen therapy can cause drying of the nasal mucosa. Also, pressure from the tubing can cause skin irritation. When you read the answer options, you will notice that the only answer that addresses the nose is the correct response. Two of the other options address the cannula and not the client. There should be no mist with oxygen administration through a nasal cannula.

Which action should a nurse recommend be included in a plan of care for clients diagnosed with schizophrenia and who are taking an antipsychotic medication?

Limit caloric and fat intake to minimize weight gain Many of the antipsychotics or neuroleptics can cause excessive weight gain over time. Limiting calories and fat intake, avoiding a sedentary lifestyle and increasing physical activity will help minimize the client's weight gain.

The nurse recognizes fluid sounds during the auscultation of a client's lung. What is the best way to document these sounds?

Low-pitched and rumbling Crackles, which indicate moisture or fluid in the lung, are described as discontinuous, low-pitched rumbling sounds that are hyper-resonant. They are more commonly heard during inspiration. "Dry and grating" would best describe a friction rub, either of the pericardial sac or the pleural lining. Stridor is the result of a larger, upper airway constriction; it sounds like intense continuous, monophonic wheezes. Wheezing can be described as high-pitched and musical; this sound indicates a narrowed lower airway such as the bronchials.

The nurse is assisting in the plan of care for a 10 month-old infant diagnosed with bacterial meningitis. The nurse would expect the plan of care to include which intervention?

Observe for a decrease in play activity When treating meningitis, the nurse should frequently assess for any neurological deterioration. In children, a decrease in play activity is equivalent to a decreased level of consciousness. Depending on the infective organism, the child may need to be on droplet precautions for 24 hours and then standard precautions, but not contact precautions. You should note that because the question involves a neurological issue, it will require a neurological answer.

A nurse is caring for a 75 year-old client diagnosed with colorectal cancer. Because the client's pain is no longer being controlled with a non-opioid analgesic, the health care provider has ordered a narcotic analgesic. What should the nurse recognize about the appropriateness of the order?

Older adult clients with cancer pain are frequently under-medicated. Ordering an opioid analgesic to manage cancer pain is appropriate and should be offered around-the-clock. The importance of assessing and treating pain appropriately is critical for anyone experiencing pain.

The nurse is assisting a client who reports having watery diarrhea. The client is asking for assistance with meal planning. Which menu choice should the nurse reinforce that the client should avoid?

Orange juice- is contraindicated for a client with diarrhea. Given the choices, it would have more tendency to increase the motility of the gastrointestinal tract. Bananas are bland and easily digested. Although dairy products should be avoided, yogurt is an exception because of its live or active cultures. Teas are a better choice than coffee, and especially the herbal, caffeine-free varieties that can help replace lost fluids.

An 80 year-old client diagnosed with chronic obstructive pulmonary disease (COPD) and acute respiratory difficulty is receiving oxygen per nasal cannula at two liters per minute. Which observation during nursing rounds should receive a nurse's immediate attention?

Oxygen saturation of 85% The highest priority in this situation is correcting the client's hypoxemia, which is demonstrated by the low oxygen saturation level. Clients with COPD should maintain an oxygen saturation level of 88 to 91%, and as much oxygen should be given as needed to maintain that goal, without raising the saturation level too high. The oxygen administration has the potential to depress the respiratory drive of those with COPD, but it will only occur in the setting of high oxygen saturation levels (92-95%). The term "immediate attention" implies a significant problem that will appear in the correct answer. You will note that this is a respiratory question and needs a respiratory response that considers both the COPD and the administration of oxygen. A respiratory rate of 32 may be the client's baseline rate in COPD; therefore, this number would need to be compared with previous findings to determine if it was a significant change that requires attention.

A nurse checks a 2 day-old infant and notices that the breasts are enlarged bilaterally with a white, thin discharge. What is the appropriate action by the nurse?

Record the findings on the nurses notes because these are "normal" findings Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to few weeks after birth. This is an expected normal finding and would be noted on the nurses' notes.

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?

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 client has just undergone electroconvulsive therapy (ECT). What is a post-procedure nursing intervention following this procedure?

Remain with the client until is oriented Clients commonly awaken 20 to 30 minutes after treatment and are groggy and confused. Therefore, the nurse should remain with the client until the client is oriented and able to engage in self care. Memory loss after ECT is typically short-term. Once home, the client may sleep longer than six hours. To select an answer to this question, you should determine which of the options is a nursing intervention. There are two nursing interventions given, but because seizures are very rare following ECT, the best response is to remain with the client (think safety).

The nurse is caring for a client who is on mechanical ventilation. What is the best evidence that the client needs endotracheal suctioning?

Rhonchi throughout the lungs Rhonchi occur from mucous in the airways and suggests the need for suctioning. Wheezes and friction rub are abnormal lung sounds, but they do not indicate a need for suctioning. The term "wheeze" in one option means the client would have a narrowed airway and so suctioning would not apply. Decreased breath sounds is too general of an answer for such a specific question. "Friction rub" is associated with sounds from tissue (usually heart or lung) rubbing together; suctioning is not indicated in cases involving a friction rub.

The licensed practice nurse (LPN) and family members witness a hospitalized child having a grand mal seizure. The child vomits immediately after the seizure. What should be a priority nursing concern to discuss with the registered nurse (RN)?

Risk for aspiration related to loss of consciousness and vomiting The tonic-clonic or grand mal seizure appears suddenly and often leads to a brief loss of consciousness. The greatest risk for the child is from airway blockage and aspiration during vomiting. Notice that only the correct option addresses both the seizure and vomiting, which are found in the content of the question.

The nurse is participating in the plan of care for an infant. Which need does the nurse understand is the most important in order to develop a feeling of trust in a 6 month-old infant?

Security While infants have many physical needs, they must be touched, loved and stimulated in order to develop security and trust. You will notice that three of the options involve physical needs. Because the question is asking about developing a "feeling of trust," you should look for the option that concerns the emotional aspect of development, which is "security."

A nurse is caring for a client who is receiving methyldopa. Which assessment finding would indicate to the nurse that the client may be having an adverse reaction to the medication?

Sedation Methyldopa (Aldomet) is used to treat hypertension. The nurse should assess the client for alterations in mental status, such as sedation. Other common side effects are dizziness, dry mouth, headache and weakness. These changes should be reported to the health care provider.

The practical nurse understands that time management is important. Which action best describes the application of time management strategies for the nurse in a charge position?

Set daily goals to prioritize the workload of self and the team Time management strategies must include setting priorities and meeting goals on a daily, weekly, monthly or yearly basis. The incorrect responses are approaches that are not the best application of time management strategies. Being efficient may not result in effectiveness. A charge nurse who often has other critical responsibilities should avoid taking a "fair share." Role modeling may be demonstrated in other ways. Tasks should be delegated based on skill levels not on equal assignment loads.

A client is being discharged with a prescription for chlorpromazine. Before the client leaves the hospital, the nurse should remind the client to report which findings within 24 hours after discharge?

Sore throat, fever Chlorpromazine is used to treat the symptoms of schizophrenia and other psychotic disorders. A sore throat and fever may be findings of agranulocytosis, which a severe decrease in granulated white blood cells. This adverse effect would predispose the client to severe infections. Although findings such as change in libido and breast enlargement are associated with chlorpromazine, they would not occur in 24 hours. A stuffy nose is also a side effect of this medication, but it is not life-threatening.

When reinforcing discharge instructions to a client who takes alprazolam (Xanax), the nurse should include which important piece of information?

Sudden cessation of alprazolam can cause rebound insomnia and nightmares. Other withdrawal findings include nervousness, irritability, sweating, lightheadedness, abdominal and muscle cramps, tremors and seizures. Before discontinuing any benzodiazepine, the dosage should be gradually decreased.

A nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first take what action?

The first step in basic life support (BLS) is to establish unresponsiveness. Calling for help and checking for a pulse are actions that should follow establishing unresponsiveness. Getting a history of the fall should follow after the clinical situation has been resolved and stabilized. You will note that the correct response is the only data collection answer. The other options are actions or interventions.

The nurse observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum on a newborn infant. What would be a priority focus when the nurse talks to the parents?

The identification of this cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Facial abnormalities including small head (microcephaly); small maxilla (upper jaw); short, up-turned nose; smooth philtrum (groove in upper lip); smooth and thin upper lip; and narrow, small, and unusual-appearing eyes with prominent epicanthal folds. The palpebral fissure separates the upper and lower eyelids.

A 2 year-old child is brought to the emergency department at 2:00 pm. The mother states that the child has not had a wet diaper all day. The child is pale and the heart rate is 132. What data should the nurse obtain next?

The status of the child's play activity that day Clinical findings of acute dehydration in children include lethargy, decreased play activity, sunken eyes, increased pulse, and dry mucous membranes and skin. The normal pulse rate for a child this age is 70-110 BPM. The change in the child is acute, so looking at changes during the past day is more appropriate than changes over a longer period of time.