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After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? a) It is typically seen with breech births. b) It usually lasts a day or two before resolving. c) It is unusual when the brow is the presenting part. d) Surgical intervention may be necessary to alleviate pressure. - ✔✔b)it usually lasts a day or two before resolving Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary. A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client's laboratory reports to determine which potential complication of the client's symptoms? a) hyperalbuminemia b)thrombocytopenia c)hypokalemia d)hypercalcemia - ✔✔c)hypokalemia Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.
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A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response? a) "What has your neighbor been doing that bothers you?" b) "How long have you been hearing these terrible voices?" c) "We won't let your neighbor visit, so you'll be safe." d) "What exactly are these terrible voices saying to you?" - ✔✔d)"What exactly are these terrible voices saying to you?" Explanation: The nurse needs to collect additional information about the client's report about hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first. Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? a) The nurse dries from finger tips down toward elbows. b) The nurse dries from forearms up toward fingers. c) The nurse keeps hands lower than elbows while washing. d) The nurse uses at least 3 to 5 mL of liquid soap. - ✔✔b)The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices. Which fetal presentation is most favorable for birth?
d) Instruct the client to modify work hours during the first trimester. - ✔✔b)Instruct the client to take at least two rest breaks during the workday. Explanation: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. For the working pregnant client, it is advisable to take two 10 - to 15 - minute breaks within an 8-hour workday. While at home the client should nap or rest if she feels sleepy or tired. People need different amounts of sleep to help them feel rested. Telling the client to get 9 hours is a good suggestion, but it isn't helpful or practical if the client needs normally needs significantly more or less than that. In general, 7-8 hours is adequate. Modifying work hours can be suggested, but many times this is not something within the client's control. Fatigue will most likely improve during the second trimester, but that does not address the client's immediate concerns. Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? a) It determines fetal lung maturity. b) It is noninvasive using real-time ultrasound. c) It will correlate with the newborn's Apgar score. d) It requires the client to have an empty bladder. - ✔✔b)It is noninvasive using real-time ultrasound. Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity. Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound requires the mother to have a full bladder. Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? a) Change the dressing. b) Elevate the head of the bed.
c) Test the fluid for glucose. d) Notify the health care provider (HCP). - ✔✔c)test the fluid for glucose Explanation: Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid. Excessive fluid leakage should be reported to the HCP. The nurse should not change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon. Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures. The nurse should notify the HCP after testing the fluid for glucose. When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? a) It can be adjusted to a position of comfort. b) It is used to lift the child. c) It adds strength to the cast. d) It is necessary to turn the child. - ✔✔c)it adds strength to the cast Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast. Upon initial assessment of a postoperative client, the nurse identifies that the I.V. infusion is different from the solution ordered by the physician. What is the first action the nurse should take? a) Discontinue the I.V. at the insertion site. b) Assess the client, call the physician, and then hang the ordered solution. c) Let the current IV. bag infuse while calling the physician to confirm the order. d) Replace the current I.V. with the ordered IV after the current I.V. finishes. - ✔✔b)Assess the client, call the physician, and then hang the ordered solution
and development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the health care provider (HCP). The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? a) hamburger, salad, and milkshake b) baked liver, green beans, and coffee c) spaghetti with tomato sauce, salad, and coffee d) fried chicken, green beans, and skim milk - ✔✔c)spaghetti with tomato sauce, salad, and coffee Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low- cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol. A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? a) a 2 - year-old child who nearly drowned 2 days earlier b) a 19 - month-old infant who had surgery for a fractured tibia 12 hours ago c) a 6 - month-old infant who has gastroenteritis and vomits every 30 minutes d) a 17 - month-old infant who lost consciousness 2 hours earlier because of a head injury - ✔✔a)a 2 - year- old child who nearly drowned 2 days earlier Explanation: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical. The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse?
a) Ask the client to state name and birthdate. b) Give client paper and pencil with which to write name and birthdate. c) Recall the client's facial features to verify the client's identity. d) Ask two staff members to state the name of the client in the room. - ✔✔a)Ask the client to state name and birthdate. Explanation: The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write his or her name and birthdate as a client has ataxia, not apraxia. Ataxia involves muscle movement, typically in the arms and legs. Apraxia involves speech. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity. The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy? Select all that apply. a) taping all IV tubing connections b) wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material d)wearing a long-sleeved gown when administering chemotherapy - ✔✔b)wearing gloves when handling the client's urine c) disposing of chemotherapy waste as hazardous material Explanation: Nurses preparing and administering chemotherapy wear gloves and a disposable, long- sleeved gown. Antineoplastic agents are disposed of as hazardous material and gloves are always worn when handling the excretions of clients who have received chemotherapy. It is not appropriate to tape IV tubing connections; antineoplastic agents are administered using Luer lock fittings on all intravenous tubing to minimize the risk of exposure from needle stick injury. Which sound should the nurse expect to hear when percussing a distended bladder? a) Hyperresonance.
b) assisting a preschool-age child in the bathroom with the door closed c) transporting a newborn in a bassinet from the mother's room to the newborn nursery d) removing a toddler from a sleeping mother's bed to the crib - ✔✔a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room Explanation: The nurse supervising a nursing assistant will need to intervene when a nursing assistant restrains a client requiring one-on-one observation to leave the room. It should be reinforced with the nursing assistant to call for a replacement for the time needed to leave the client. Assisting a preschooler in a bathroom is appropriate for that age group. Transporting an infant in a bassinet is appropriate and within the scope of the nursing assistant's job. Removing the toddler from the mother's bed to the crib is appropriate. Cosleeping is dangerous for the child, and the mother should be educated on the risks. Which client should the nurse assess first? a) a client being treated for chronic stable angina who reports a recent increase in chest pain frequency b) a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL c) a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week d) a client with chronic hypertension whose blood pressure today is 182/98 mm Hg - ✔✔a)a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress. The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? a) 1 week b) 2 to 4 weeks c) 5 to 7 weeks
d) 8 weeks - ✔✔b)2 to 4 weeks Explanation: Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose. A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin a) restores the inflammatory response. b) enhances oxygen transport to tissues. c) reduces edema. d) enhances protein synthesis. - ✔✔d)enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport. A 7 - year-old client is prescribed a clear liquid diet by the healthcare provider after tonsillectomy. What nutrition will the nurse give the child? Select all that apply. a) cream of chicken soup b) orange juice c) ice cream d) apple juice e) lime gelatin f) chicken broth - ✔✔d)apple juice e) lime gelatin f) chicken broth Explanation: Clear liquids include clear broth, gelatin, clear juices, water, and ice chips. The client can see through clear liquids. Cream of chicken soup, orange juice, and ice cream are not clear liquids. They are
A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? a) Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. b) The nurse must start the process to warn the client's husband. c) An assessment of the client's response to treatment must be performed. d) The comment must be held in confidence because the client did not report the statement directly to the nurse. - ✔✔b)The nurse must start the process to warn the client's husband. Explanation: Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons. Which question is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis? a) "Do you have any pets?" b) "Have you recently consumed alcohol?" c) "What is your occupation?" d) "How has this affected you?" - ✔✔a)"Do you have any pets?" Explanation: An infected pet may be the source of this infection. The other questions are appropriate to ask when obtaining a health history related to skin disorders but are not the priority question. As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response? a) Do nothing as this is normal behavior for a toddler. b) Encourage the parents to teach their children to share. c) Separate the children so that they cannot fight.
d) Sit between the children and encourage them to play together. - ✔✔a)Do nothing as this is normal behavior for a toddler. Explanation: Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease? a) low sodium b) high protein c) low carbohydrate d) low fat - ✔✔a)low sodium Explanation: A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease. A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client? a) Eat while lying flat. b) Raise the hips using trapeze. c) Rotate side to side. d) Flex and extend the ankle on affected side. - ✔✔b)Raise the hips using trapeze. Explanation: The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.
a) "I can offer you ibuprofen for pain with a small sip of water." b) "You are not allowed anything by mouth so that your pancreas can rest." c) "I will be starting antibiotic therapy once the blood cultures are obtained." d) "Activity is important, so you will be scheduled for physical therapy." - ✔✔b)"You are not allowed anything by mouth so that your pancreas can rest." Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management and fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain. After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification best describes dobutamine? a) Indirect-acting dual-active agent b)Direct-acting beta-active agent c)Indirect-acting beta-active agent d)Direct-acting alpha-active agent - ✔✔b)Direct-acting beta-active agent Explanation: Adrenergic agents are classified according to their method of action and the type of receptor on which they act. Direct-acting agents act on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual- acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors. Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent. One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do? a) Dim lights in the house and stay inside for one week.
b) Attach sun shields to existing eyeglasses when in direct sunlight. c) Use sunglasses that wrap around the side of the face when in bright light. d) Patch the affected eye when in bright light. - ✔✔c)Use sunglasses that wrap around the side of the face when in bright light. Explanation: To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye. A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? a) hyperabduction and extension of the arms with external rotation of the hips b) neck extension and back arching with flattened shoulders c) adduction and flexion of the extremities with gently rounded shoulders d) abduction and flexion of the arms with flattened shoulders - ✔✔c)adduction and flexion of the extremities with gently rounded shoulders Explanation: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates. The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? a) touch the client, which increases their exposure to radiation. b) work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged. c) work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.
Explanation: Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment. The nurse must provide a low-protein diet during the acute phase. The nurse must also closely monitor the client's fluid intake and output. Clients should be placed on bed rest to control hypertension and workload on the kidney. Although providing comfort measures (such as placing the client on a sheepskin) are important, this action isn't a priority. In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery? Dribbling of urine: a) can be a chronic problem. b) can persist for several months. c) is an abnormal sign that requires intervention. d) is a sign of healing within the prostate. - ✔✔b)can persist for several months Explanation: Dribbling of urine can occur for several months after TURP. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery. A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? a) pain b)depression c) sexual dysfunction d) self-consciousness - ✔✔a)pain
Explanation: The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness. A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? a) altered nutrition (less than body requirements) related to difficulty sucking b) parental sleep pattern disturbance related to the baby's feeding schedule c)knowledge deficit related to normal infant growth and development d)altered role performance related to new responsibilities within the family - ✔✔a)altered nutrition (less than body requirements) related to difficulty sucking Explanation: The nurse's initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones. A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention? a) contacting the physician b) increasing the rate of IV fluids c) reassessing vital signs in 15 minutes d) inserting a Foley catheter to monitor urine output - ✔✔a)contacting the physician Explanation: The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output. The registered nurse (RN) is referred to a client's home when spouses have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority?
