The Point: Reducing Risk 1137

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? -"I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." -"I will receive parenteral vitamin B12 therapy for the rest of my life." -"I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." -"I will receive parenteral vitamin B12 therapy monthly for 6 months to a year."

-"I will receive parenteral vitamin B12 therapy for the rest of my life."

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? -"Why don't you decide about activity after you return from recovery?" -"It is always a good idea to rest quietly after surgery, which will help minimize further pain." -"The physician will probably order you to lie flat for 24 hours." -"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

-"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

A client who is taking warfarin develops gastrointestinal bleeding. What is the nurse's priority action? -Transfuse fresh frozen plasma (FFP). -Administer ranitidine. -Administer vitamin K. -Assess the international normalized ratio (INR) level.

-Assess the international normalized ratio (INR) level.

The nurse attempts to obtain a blood specimen from an implanted port. The port does not have blood return. What should the nurse do next? -Send the client to get a chest x-ray. -Change the dressing on the implanted port. -Have the client change positions. -Remove the implanted port.

-Have the client change positions.

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). What should be the nurse's first response? -Send the client to surgery. -Call the operating room to cancel the surgery. -Notify the anesthesiologist. -Make a note on the client's record.

-Notify the anesthesiologist.

The mother calls the nurse to report that her toddler has just been burned on the arm. What should the nurse advise the mother to do first? -Pack the arm in ice and then take the child to the closest emergency department. -Rub the burned area with an antibacterial ointment and then call the child's health care provider (HCP). -Call the child's health care provider (HCP) immediately and then wrap the arm in a clean cloth. -Run cool water over the burned area and then wrap it in a clean cloth.

-Run cool water over the burned area and then wrap it in a clean cloth.

A child,who uses an inhaled bronchodilator only when needed for asthma has a best peak expiratory flow rate of 270 L per minute. The child's current peak flow reading is 180 L per minute. How does the nurse interpret this reading? -This is a medical emergency requiring a trip to the emergency department for treatment. -The child needs to use short-acting, inhaled beta-2 agonist medication. -The child's asthma is under good control, so the routine treatment plan should continue. -The child needs to use inhaled cromolyn sodium.

-The child needs to use short-acting, inhaled beta-2 agonist medication.

A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, what would the nurse most expect to find? -use of an intrauterine device for 1 year -grand multiparity (five or more births) -a history of pelvic inflammatory disease -use of a hormonal contraceptive for 5 years

-a history of pelvic inflammatory disease

The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which client would not have delayed fluid restrictions? The client who had: -a transurethral resection of a bladder tumor under general anesthesia. -an inguinal herniorrhaphy with spinal and intravenous conscious sedation. -a repair of carpal tunnel syndrome under local anesthesia. -undergone a bronchoscopy under local anesthesia.

-a repair of carpal tunnel syndrome under local anesthesia.

While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact their primary health care provider (HCP) immediately if the client experiences which symptom? -emotional stress on the job -weight gain of 1 lb (0.45 kg) in 1 week -mild ankle edema -dyspnea at rest

-dyspnea at rest

When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication? -esophageal stricture -recurrent mild diarrhea with -dehydration -gastric ulcers -speech problems

-esophageal stricture

Which finding should first alert the nurse that a child is hemorrhaging after a tonsillectomy? -requests for a drink -frequent swallowing -mouth breathing -increased pulse rate

-frequent swallowing

A nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? -hypoglycemia -muscle flaccidity -hypertensive crisis -hypotensive episodes

-hypertensive crisis

The nurse assesses a child who had a nephrectomy for a Wilms tumor. The nurse should assess the child postoperatively for which early sign of a complication? -increased urine output -increased abdominal distention -elevated blood pressure -increased respiratory rate

-increased abdominal distention

After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider? -laryngeal stridor -green sputum -hemoptysis -dry cough

-laryngeal stridor

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report -light flashes and floaters in front of the eye. -a recent driving accident while changing lanes. -frequent episodes of double vision. -headaches, nausea, and redness of the eyes.

-light flashes and floaters in front of the eye.

The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to: -facilitate osmotic diuresis. -promote urination. -equalize intake and output. -maintain fluid and electrolyte balance.

-maintain fluid and electrolyte balance.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? -paper straw -single-hole nipple -plastic spoon -rubber dropper

-rubber dropper

A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings? -fibrinogen level of 75 mg/dL (2.21 µmol/L) -platelet count of 80 x 103/mm3 (80 X 109/L) -serum calcium level of 5 mg/dL(1.25 mmol/L) -partial thromboplastin time of 38 seconds

-platelet count of 80 x 103/mm3 (80 X 109/L)

The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the health care provider? -potassium: 2.2 mEq/L (2.2 mmol/L) -glucose, fasting: 204 mg/dl (11.32 mmol/L) -creatinine: 2.0 mg/dl (176.8 µmol/L) -sodium: 136 mEq/L (136 mmol/L)

-potassium: 2.2 mEq/L (2.2 mmol/L)

An older adult has pruritus on the arms and legs and is scratching the affected areas. Which is the priority nursing care for this client? -avoiding social isolation -instructing the client not to scratch -preventing infection -increasing fluid intake

-preventing infection

Which statement heard during shift report identifies an important priority for action? -A postoperative client's pulse has been increasing, and the blood pressure is decreasing. -A client is reluctant to ambulate on the evening of surgery. -A postoperative client is drowsy and slow to respond when the analgesic is at its maximal effect. -A postoperative client has not voided for 5 hours after surgery.

-A postoperative client's pulse has been increasing, and the blood pressure is decreasing.

The health care provider prescribes a maternal blood test for alpha fetoprotein for a nulligravid client at 16 weeks' gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition? -neural tube defects -inborn errors of metabolism -Rh incompatibilities -Lecithin-sphingomyelin ratio

-neural tube defects

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? -nasal cannula flow rate -IV fluid infusion rate -pedal pulses -capillary refill

-pedal pulses

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? -published national standards -policies from other hospitals -data from retrospective studies -expert opinions

-published national standards

A client seeks care for hoarseness that has lasted for 1 month. What is the most important question for the nurse to ask when assessing the client's health history? -"Do you smoke cigarettes, cigars, or a pipe?" -"Have you strained your voice recently?" -"Do you experience frequent heartburn?" -"How many alcoholic beverages do you drink each week?"

-"Do you smoke cigarettes, cigars, or a pipe?"

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching? -"I won't go to see my siblings while they have a cold." -"I can eat whatever I want as long as it's low in fat." -"I won't go to see my cousins right after they gets their vaccines." -"I stopped smoking last year; this year I'll quit drinking alcohol."

-"I can eat whatever I want as long as it's low in fat."

The nurse is assisting with spirometry testing for a 6-year-old child with asthma. What instruction is most important for the nurse to give the child to obtain an accurate reading? -"Breathe out as hard as possible, and then breathe in deeply." -"Blow quickly into the mouthpiece using the pursed-lip method." -"Hold the mouthpiece loosely between your lips while performing the test." -"You will only need to do this once, so give us your best effort."

-"Breathe out as hard as possible, and then breathe in deeply."

The nurse is teaching a client with type I diabetes self-administration of insulin. Which statement by the client would be an expected outcome of the teaching session? Select all that apply. "It is ok for me to skip my insulin dose if I feel that my blood sugar is not elevated." -"If I lose weight and control my carbohydrate intake, I can progress to diabetic pills." -"I need to make sure that I eat my meals and snacks on time after I take my insulin." -"If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications." -"If I exercise more than is normal, there is a risk that I might become hypoglycemic."

-"I need to make sure that I eat my meals and snacks on time after I take my insulin." -"If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications." -"If I exercise more than is normal, there is a risk that I might become hypoglycemic."

Caregivers of an infant with a feeding button style gastrostomy tube mention to the nurse there is leaking present. What action should the nurse take? -Reassure caregivers that some leakage is expected and apply barrier cream. -Ask caregivers to demonstrate how they hook up the tube to the feeding button. -Teach the caregivers how to use gauze around the button to absorb leakage. -Assess if the leakage is coming from valve failure or from the peristomal area.

-Assess if the leakage is coming from valve failure or from the peristomal area.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern? -Cheyne-Stokes respiration -obstructive sleep apnea -Biot's respiration -hyperventilation

-Cheyne-Stokes respiration

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolbutamide. Which laboratory test is the most important for confirming this disorder? -serum sodium level -arterial blood gas (ABG) values -serum osmolarity -serum potassium level

-serum osmolarity

A 24-year-old primigravid client in active labor asks to use the jet hydrotherapy tub to aid in pain relief. Which condition would the nurse consider to be a contraindication for hydrotherapy? -diabetes mellitus -hypotonic labor patterns -ruptured membranes -multifetal gestation

-ruptured membranes

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. Which additional assessment finding will the nurse assess for? -severe abdominal pain with direct palpation or rebound tenderness -tenderness and pain in the right upper abdominal quadrant -rectal bleeding and a change in bowel habits -jaundice of the sclera and nausea and vomiting

-severe abdominal pain with direct palpation or rebound tenderness

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.) -skin temperature. -pain in extremity. -fluid intake. -nausea. -nail bed color.

-skin temperature. -pain in extremity -nail bed color.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission? -Assess the imminence of birth. -Assess the client's coping skills in labor. -Ensure that the client will have a support person in labor. -Review the client's obstetrical history.

-Assess the imminence of birth.

The nurse teaches the parents of a 2-year-old child how to instill antibiotic eardrops. Which statement about the direction to pull on the earlobe indicates that the child's father has understood the teaching? -"I should pull the earlobe up and forward." -"I should pull the earlobe up and backward." -"I should pull the earlobe down and outward." -"I should pull the earlobe down and backward."

-"I should pull the earlobe down and backward."

The nurse is teaching dietary considerations to a client who had a gastric resection. The nurse understands that the instruction has been effective if the client says which statement? -"I will limit protein intake." -"I will only have 30 mL of fluid with each meal." -"I will drink three glasses of milk each day." -"I will rest for 30 minutes after eating."

-"I will rest for 30 minutes after eating."

A preschooler with a history of repaired lumbar myelomeningocele is in the emergency department with wheezing and skin rash. Which question should the nurse ask the parent first? -"Is your child allergic to bananas or any other food?" -"Is your child taking any medications?" -"Who brought your child to the emergency department?" -"What are you doing to treat your child's skin rash?"

-"Is your child allergic to bananas or any other food?"

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate, the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? -"When my moods fluctuate, I'll increase my dose of lithium." -"Eating too much watermelon will affect my lithium level." -"A good blood level of the drug means the drug concentration has stabilized." -"I can still eat my favorite salty foods."

-"When my moods fluctuate, I'll increase my dose of lithium."

A nurse assessing the heart rate and rhythm of an 8-year-old child hears a murmur that's barely audible even in a quiet room. The child's heart rate is 80 beats/minute. The nurse should document her assessment findings as: -"heart rate regular, grade II murmur auscultated." -"heart rate bradycardic, grade II murmur auscultated." -"heart rate regular, grade I murmur auscultated." -"heart rate bradycardic, grade I murmur auscultated."

-"heart rate regular, grade I murmur auscultated."

Which laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy? -activated partial thromboplastin time (APTT) -international normalized ratio (INR) -thrombin time -prothrombin time (PT)

-activated partial thromboplastin time (APTT)

An older adult client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which client information would most likely be a predisposing factor for the diagnosis of pneumonia? -vegetarian diet -osteoarthritis -age -daily bathing

-age

For a client with a Wilms' tumor, which preoperative nursing intervention takes highest priority? -restricting oral intake -monitoring acid-base balance -maintaining strict isolation -avoiding abdominal palpation

-avoiding abdominal palpation

Which nursing intervention for catheter care should have the highest priority? -clamping the catheter periodically to maintain muscle tone -irrigating the catheter with several milliliters of normal saline solution -changing the location where the catheter is taped to the client's leg -cleaning the area around the urethral meatus

-cleaning the area around the urethral meatus

When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that the client: -is scheduled for a brain scan immediately after the procedure. -sees family members immediately before the procedure. -has been on nothing-by-mouth (NPO) status for no more than 2 -hours before the procedure. -has undergone a thorough medical evaluation.

-has undergone a thorough medical evaluation.

Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The client is not able to make a sound. The nurse determines that the client is experiencing which complication of the surgery? -internal hemorrhage -decreasing level of consciousness -upper airway obstruction -laryngeal nerve damage

-laryngeal nerve damage

Which symptom is an early indication that the client's serum potassium level is below normal? -muscle weakness in the legs -tingling in the fingers -diarrhea -sticky mucous membranes

-muscle weakness in the legs

On reviewing a child's laboratory results, the nurse notes a serum potassium level of 3.3. What should the nurse encourage the child to drink? -apple juice -grape juice -orange juice -cranberry juice

-orange juice

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing -motor loss in the legs that exceeds that in the arms. -nuchal rigidity and Kernig's sign. -pupillary changes. -raccoon's eyes and Battle's sign.

-raccoon's eyes and Battle's sign.

A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention? -encouraging early ambulation -reorienting the client to time and place -monitoring the client's vital signs every hour for 4 hours -placing the client in Trendelenburg's position

-reorienting the client to time and place

Two hours ago, a neonate at 38 weeks' gestation and weighing 3175 g (3.18 kg) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the health care provider (HCP)? -temperature instability -alkalosis -positive Babinski reflex -increased muscle tone

-temperature instability

When admitting a client with a fractured extremity, what area should the nurse assess first? -the opposite extremity for baseline comparison -the actual fracture site -the area proximal to the fracture -the area distal to the fracture

-the area distal to the fracture

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings may signify: -need for labor induction. -umbilical cord prolapse. -infection. -start of the second stage of labor.

-umbilical cord prolapse.

A primigravid client at 28 weeks' gestation tells the nurse that they and their spouse wish to drive to visit relatives who live several hours away. Which recommendation by the nurse would be best? -"Taking the trip is okay if you stop every 1 to 2 hours and walk." -"Limit the time you spend in the car to a maximum of 4 to 5 hours." -"Try to avoid traveling anywhere in the car during your third trimester." -"Avoid wearing your seat belt in the car to prevent injury to the fetus."

-"Taking the trip is okay if you stop every 1 to 2 hours and walk."

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? -Administer an antihistamine for postnasal drip. -Tilt the head back. -Compress the nares. -Collect the drainage.

-Collect the drainage.

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? -Encourage the client to perform isometric leg exercise to improve circulation in the legs. -Document the findings and recheck the client in 1 hour. -Slow the I.V. fluid to prevent any more swelling at the puncture site. -Contact the physician and report the findings.

-Contact the physician and report the findings.

A client with chronic heart failure has atrial fibrillation and is taking warfarin. What should the nurse tell the client about the expected outcome of this drug? -"This medication will decrease the extra fluid your heart is circulating." -"This medication will improve the work of your heart." -"This medication will prevent a clot from forming." -"This medication will regulate the rhythm of your heart."

-"This medication will prevent a clot from forming."

A client at 11 weeks gestation calls the antepartum clinic nurse. She has soaked a perineal pad with fresh blood in less than 30 minutes. The uterine cramping has also become worse. What is the most appropriate response from the nurse? -"This is nothing to worry about. Many women have bleeding during their pregnancy." -"You need to seek immediate attention from your physician." -"I am sorry. There is nothing to do because you are likely miscarrying." -"Lie down and call your physician tomorrow if your symptoms are continuing."

-"You need to seek immediate attention from your physician."

When making rounds on the pediatric neurology unit, the nurse manager notes that when giving IV medications many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice? -Post an evidence-based article on the unit. -Ask each nurse if they are aware that their practice is not current. -Create a poster presentation on the topic with a required posttest. -Send a group email discussing the importance of clamping the device first.

-Create a poster presentation on the topic with a required posttest.

A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, "What does that mean?" The nurse explains that a reactive nonstress test indicates which of the following about the fetus? -Evidence of late decelerations occurring during the test. -Fetal well-being at this point in the pregnancy. -Evidence of some compromise that will require birth soon. -No accelerations demonstrated within a 20-minute period.

-Fetal well-being at this point in the pregnancy.

A 4-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery? -Show the child a visual analog scale (VAS) based on a scale from 0 to 10. -Show the child a video about the surgery. -Explain how to use a patient-controlled analgesia (PCA) pump for pain control. -Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.

-Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.

A middle-aged female with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which action should the nurse suggest? -See the health care provider immediately. -Elevate the arm on two pillows. -Apply warm compresses to the affected arm. -Apply a compression sleeve.

-See the health care provider immediately.

The nurse teaches the three cardinal signs of choking and total airway blockage to the parents of a toddler who was treated for a foreign body obstruction. When asked to repeat the signs, the parents identify "turn blue" and "cannot speak." What third sign would the parents identify if teaching was successful? -gags -gasps -collapses -vomits

-collapses

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? -medication allergies -ability to deep breathe -presence of carotid pulse -swallow reflex

-swallow reflex

A cerclage procedure is performed on a client at 20 weeks' gestation who is diagnosed with cervical incompetence. When preparing the discharge teaching plan, the nurse should expect to instruct the client to monitor herself for which problem? -transient hypotension -nausea and vomiting -Braxton Hicks contractions -symptoms of infection

-symptoms of infection

A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client? -"PTCA involves passing a catheter through the coronary arteries to find blocked arteries." -"PTCA involves cutting away blockages with a special catheter." -"PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." -"PTCA involves inserting grafts to divert blood from blocked coronary arteries."

-"PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter."

A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? -"You will not feel the local anesthetic being applied because it will be sprayed on." -"After the needle is removed, you will feel a bandage being applied around your chest." -"You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders." -"You will feel a pulling type of discomfort for a few seconds."

-"You will feel a pulling type of discomfort for a few seconds."