The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted with a connection to a ventilator. Which finding
... [Show More] should prompt the nurse to take immediate action to resolve the issue?
A. Client is unable to speak
B. Mist is visible in the T-Piece of the ventilator circuit
C. Pulse oximetry of 86% saturation
D. Breath sounds are heard bilaterally
C
Pulse oximetry should not be lower than 90% saturation. Breath sounds are heard bilaterally so the placement of an ET is most likely in proper position. The ventilator settings will need to be rechecked. A client with an ET tube in place will not be able to talk when the ET tube balloon is inflated.
In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize which approach?
A. Eat smaller meals
B. Limiting alcohol use
C. Avoiding passive smoke
D. Learning relaxation techniques
D
The only factor that can enhance the client's response to pain medication for angina is reduction of anxiety through relaxation methods. Anxiety may increase intensity to a point where pain medication outcomes are totally ineffective.
The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a priority?
A. Altered parenting
B. Social isolation
C. Ineffective coping
D. Sexual dysfunction
A
The mother who abuses cocaine puts her newborn and any other children at risk for neglect and abuse. The continued use of drugs has the potential to impact parenting behaviors. Social service referrals are indicated for evaluation and follow-up.
A nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. Which intervention should the nurse take first?
A. Assess the family's patterns for dealing with death
B. Ask about their present religious affiliations
C. Explain the stages of death and dying to the family
D. Recommend an easy-to-read book on grief
A
When a new problem is identified, it is important for the nurse to first collect accurate information. This is crucial to ensure that the client and the family's needs are adequately identified in order to plan and implement nursing care. Once the situation has been assessed and a plan has been established, the nurse can focus on teaching or referral to other resources.
A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of voiding on the floor by which of these approaches?
A. Require the client to mop the floor after each incident
B. Restrict the client's fluids throughout the day
C. Toilet the client more frequently with supervision
D. Withhold privileges each time the voiding occurs
C
With a client that has altered thought processes, the appropriate nursing approach to change behaviors is to take an active role in attending to the physical needs of the client. The other options are incorrect approaches.
A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take Alka-Seltzer for an upset stomach?" What is the best response by the nurse?
A. "Use about half the recommended dose of Alka-Seltzer."
B. "Select another antacid that does not inactivate warfarin (Coumadin)."
C. "Avoid Alka-Seltzer because it contains aspirin."
D. "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)."
C
Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin is an antiplatelet drug and taking this with warfarin will potentiate the anticoagulant effects of warfarin (Coumadin), which may increase the risk of bleeding.
At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being evaluated for cerebral palsy (CP). Which information provided by the parents would support this diagnosis?
A. "Our child isn't talking yet."
B. "We think our child seems smaller than other babies this age."
C. "Mealtime is so messy when he tries to feed himself."
D. "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg."
D
Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity, infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born prematurely, it would be expected that he would be smaller than other babies. At this age, most children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy.
The parent of an 8-month-old infant asks the nurse if the child's language development is normal for this age. Which sounds should the nurse expect at this age? (Select all that apply.)
A. Single vowel sounds such as ah, eh and uh
B. Combining syllables (e.g., "dada")
C. Cooing, gurgling and laughing aloud
D. Imitating sounds
E. Crying for 1-1 1/2 hours per day
B,D
In the first few weeks of life, crying has a reflexive quality and is mostly related to the child's physiologic needs. Infants cry for 1-1 1/2 hours per day until up to 3 weeks of age and then build up to 2 hours and even 4 hours by 6 weeks of age. Crying tends to decrease by 12 weeks.
Normal infant language development milestones:
Around 2 months: Single vowel sounds such as ah, eh and uh
By 3-4 months: Cooing, gurgling and laughing aloud
By 6 months: Imitating sounds and combining syllables (e.g., "dada")
A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority?
A. Show the mother films on the physiology of lactation
B. Give the mother several illustrated pamphlets
C. Give the mother privacy for the initial feeding
D. Assist the mother to position the newborn at the breast
D
All of the approaches should be helpful in teaching. However, the priority is to place the infant to the breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
The nurse is collecting data from an adolescent client. Which of the following issues should the nurse address? (Select all that apply.)
A. "Where are you currently living?"
B. "How are things going at home?"
C. "Have you decided what you are going to do after high school?"
D. "Are you currently having conflicts with someone close to you?"
E. "How many sexual partners have you had in the past six months?"
F. "Have you gotten in any trouble lately?"
A,B,D,E
Several professional organizations have published guidelines aimed at improving and maintaining health care for adolescents and young adults. The American Academy of Pediatrics, American Academy of Family Physicians, American Medical Association and U.S. Preventive Services Task Force have similar guidelines for health supervision of adolescents. These guidelines emphasize the need to provide health services to adolescents that meet their physical and emotional needs.
Bright Futures (American Academy of Pediatrics, 2017) emphasizes that the following issues should be addressed with adolescents at each health visit:
Physical growth and development (physical and dental health, body image, healthy nutrition, physical activity)
Social and academic competence (relationships with peers and family, school performance, interpersonal relationships)
Emotional well-being (mental health, sexuality)
Risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs)
Violence and injury prevention
Closed-ended questions about the client's plans after high school and if they have been in trouble are non-therapeutic and not appropriate in this situation.
A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse should understand that a more frequent cause for suicide in adolescents is which factor?
A. Feelings of anger or hostility with others
B. Reunion wish or fantasy of the supernatural
C. Progressive failure to adapt socially
D. Feelings of alienation or isolation from peers
D
The isolation from peers may occur gradually to result in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings to peers or family members. During adolescence, an important benchmark is to achieve a sense of identity and peer acceptance.
The nurse is caring for a child diagnosed with seizures. While teaching the family and the child about the medication phenytoin, what information should the nurse emphasize?
A. Omit the medication if the child is seizure-free
B. Serve a diet that is high in iron
C. Administer acetaminophen to promote sleep
D. Maintain good oral hygiene and dental care
D
Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized. The medication should never be stopped, even if the child is seizure-free; sudden discontinuation could result in status epilepticus. Acetaminophen is not a sleep-aid and iron interferes with phenytoin absorption.
The nurse is performing an assessment on an infant with severe airway obstruction. Which assessment finding would the nurse anticipate?
A. Rapid, shallow respirations
B. Nasal flaring
C. Chest pain aggravated by respiratory movement
D. Cyanosis and mottling of the skin
B
When the trachea or bronchioles become partially blocked, air flow is restricted. Nasal flaring is an exaggerated opening and closing of the nostrils with breathing, and is considered a subtle but important sign of acute respiratory distress in an infant. This is an emergency and requires rapid medical intervention.
Several hours after a gastrectomy, the nasogastric tube (NGT) stops draining. After referring to the standing gastrectomy postoperative orders, what order will the nurse implement first?
A. Notify the surgeon
B. Increase the amount of suction
C. Gently irrigate the tube with sterile normal saline
D. Reposition the tube until it begins to drain
C
The nurse will assess the position and patency of the NGT, as well as the color and amount of gastric drainage. The nurse can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or repositioning the tube is needed, the nurse must call the surgeon. The NGT inserted in surgery should not be repositioned by the nurse because of the risk of disrupting any internal sutures. The NGT should be connected to low suction; it would be contraindicated to increase the suction.
A nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 F (36.7 C) at 11:00 am. At 1:00 pm the child's parent reports that the child "feels very warm" to touch. What should the nurse do first?
A. Administer the prescribed acetaminophen
B. Reassure the parent that this is normal
C. Offer the child cold oral fluids
D. Reassess the child's temperature
D
The nurse should listen to and show respect for what the parent is saying, because the parent is more sensitive to the variations in the child's condition. However, the nurse knows that a low-grade fever (99-101 F or 37.2-38.3 C) is common after surgery, which is why the nurse should first reassess the temperature before implementing any intervention. Usually the surgeon is contacted if the temperature is higher than 101.5 F (38.6 C).
A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective?
A. "The inhaler can be used whenever I feel short of breath."
B. "If I forget a dose, I can double up on the next dose."
C. "I should rinse my mouth after using the inhaler."
D. "I should not use a spacer with my inhaler."
C
Fluticasone inhaled (Flovent Diskus) is an inhaled corticosteroid used to prevent asthma attacks. It is often used in conjunction with a bronchodilator. The client should be instructed to rinse the mouth after using the inhaler to wash away any steroid residue so as to reduce the risk of oral fungal infections.
A diabetic client asks the nurse: "Why did the health care provider order a glycosylated hemoglobin (HbA1c) measurement? My blood glucose reading was just done this morning." Which explanation would be best to help explain the purpose of the HbA1c?
A. Provides a more precise blood glucose value than self-monitoring
B. Reflects an average blood glucose for the prior several months
C. Is performed to detect any complications of diabetes
D. Measures the circulating levels of insulin
B
The HbA1c is used to determine how well the client is managing the disease. The results reflect the average blood sugar level for the past 2 to 3 months; the more glucose in the blood, the more hemoglobin gets glycated (coated with glucose). The higher the HbA1c, the poorer the glucose management and the higher the risk of diabetic complications. For most diabetics, the goal is to keep the HbA1c at or below 6.5 - 7 %.
A nurse is observing a client during an excretory urogram. Which of these observations indicate there is a complication?
A. Within two minutes of the dye injection the client states, "I have a feeling of getting warm."
B. A client complains of a salty taste in the mouth when the dye is injected
C. Within one minute after the dye is injected the client's entire body turns a bright red color
D. Five minutes into the procedure the client gags and states, "I am getting sick."
C
This observation suggests anaphylaxis from the dye injection, which can cause massive vasodilation and shock. Other findings of anaphylaxis are immediate wheezing and/or respiratory arrest. The salty taste in the mouth, the feeling of warmth and the complaint of nausea are expected side effects of the injection of the dye.
A client diagnosed with testicular cancer is scheduled for a right orchiectomy. The nurse is able to answer the client's questions about this procedure with the understanding that a unilateral orchiectomy involves which of the following approaches?
A. A dissection of related lymph nodes by the testes
B. A surgical removal of one testicle
C. A partial surgical removal of the perineal area
D. A surgical removal of the entire scrotum
B
The affected testicle is surgically removed along with its tunica and spermatic cord. The other genitals and the perineal area are not involved.
A client has been taking alprazolam for three days. The nurse should expect to find which intended effect of this drug?
A. Tranquilization and calming effects
B. Increased coordination and ability to concentrate
C. Relief of insomnia and phobias
D. Sedation and long-term analgesia
A
Alprazolam (Xanax) is a benzodiazepine used in the treatment of anxiety, panic disorder, and anxiety associated with depression; it is also beneficial to those suffering from sleep disorders. This medication is a central nervous system depressant, producing a drowsy or calming effect; it may cause a lack of coordination. Alprazolam has a very short half-life and produces immediate symptom relief. It does not cause analgesia nor is it used to treat phobias.
During a routine checkup, a client with a history of type 1 diabetes mellitus has the glycosolated hemoglobin (HbA1c) checked. The results indicate a level of 11%. Based on this result, what should the nurse emphasize during teaching?
A. Rotation of injection sites
B. Daily peripheral glucose monitoring
C. Insulin mixing and preparation
D. Review of diet and exercise recommendations
B
Normal results for Hg A1c (glycosolated hemoglobin) is 6% or less. Persons diagnosed with diabetes mellitus have guidelines designated by their health care provider; usually it's less than 7%. Hemoglobin A1c is an average serum glucose level for the prior three months. The peripheral stick for glucose is an approach to monitor daily fluctuations.
A nurse is teaching the parent of a 9 month-old infant about diaper dermatitis. Which of these actions would be appropriate for the nurse to include during the teaching?
A. Stop any new food that was added to the infant's diet prior to the rash
B. Use commercial baby wipes with each diaper change
C. Do not use occlusive ointments on the rash
D. Use only cloth diapers that are rinsed in bleach
A
The addition of new foods to the infant's diet commonly can cause diaper dermatitis. The other actions are incorrect to deal with this problem.
The nurse is assessing a client with a history of hypertension. Which of these questions is a priority for the nurse to ask?
A. "Describe your usual exercise and activity patterns."
B. "What over-the-counter medications do you take?"
C. "Describe your family's cardiovascular history."
D. "Tell me about your usual diet for one day."
B
Over-the-counter medications (OTC), especially those that contain cold preparations, can increase the blood pressure to the point of aggravation of the hypertension. The nurse would ask the other questions, but the answers to these questions don't have as great a risk for the client as the question about OTC medications.
A novice charge nurse is delegating duties. Which tasks, if delegated to an unlicensed assistive personnel (UAP), would require intervention by the nurse manager?
A. To empty a urethral collection bag
B. To feed a 2 year-old with a broken arm
C. To bathe a woman with internal radon seeds and device
D. To help an older adult client to the bathroom
C
A client with internal radiation is complex care and is not suitable to be assigned to a UAP. Additionally, the client would not receive a complete bath because movement is minimized during this therapy to prevent the slippage of the device.
A nurse consistently ignores the call lights of clients who practice alternative lifestyles. The nurse's behavior is an example of what approach?
A. Stereotyping
B. Cultural insensitivity
C. Prejudice
D. Discrimination
D
Discrimination is the differential treatment of individuals because they belong to a minority group. This generally refers to the limiting of opportunities, choices, or life experiences because of prejudices against individuals, cultures or social groups.
The client is admitted in stable condition from the emergency department. Based on the ECG strip, the nurse anticipates which of the following types of medications will be ordered? (Select all that apply.)
Strip shows Atrial Flutter
A. Calcium channel blocker
B. Beta blocker
C. Diuretic
D. Vasodilator
E. Cardiac glycoside
A,B,E
This ECG depicts atrial flutter, when the atria beat excessively fast (250-300 BPM). Medications used to slow the heart include calcium channel blockers (such as diltiazem), beta-adrenergic blockers (such as propranolol), and a cardiac glycoside (digoxin). An anticoagulant (such as warfarin) may also be ordered. Vasodilators and diuretics are used to lower blood pressure; vasodilators will increase heart rate.
A 55 year-old woman is taking prednisone and aspirin (ASA) as part of the treatment for rheumatoid arthritis. Which approach would be an appropriate intervention for the nurse?
A. Assess the pulse rate every four hours
B. Monitor tBoth prednisone and ASA can lead to gastrointestinal bleeding. Therefore, monitoring for occult blood is indicated.he level of consciousness every shift
C. Test stools for occult blood
D. Discuss fiber in the diet to prevent constipation
C
Both prednisone and ASA can lead to gastrointestinal bleeding. Therefore, monitoring for occult blood is indicated.
A client diagnosed with hypertension is started on atenolol. The nurse should instruct the client to immediately report which of these findings?
A. Feeling tired
B. Slow, irregular pulse
C. Decreased sex drive
D. Insomnia
B
Most of the side effects for the beta-blocker, atenolol (Tenormin) are transient or mild, such as decreased sex drive, low energy or feeling tired, depression or insomnia. However the client should understand that he needs to call the health care provider if he experiences any of these serious side effects: slow or uneven heartbeats, feeling short of breath, lightheadedness, fainting, or swelling of the feet or ankles.
A nurse is caring for a client with schizophrenia who has been treated with quetiapine for one month. Today the client is increasingly agitated and reports having muscle stiffness. Which of these additional findings should be reported to the health care provider?
A. Decreased pulse and blood pressure
B. Mental confusion and general weakness
C. Elevated temperature and sweating
D. Muscle spasms and seizures
C
Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increased creatine phosphokinase (CPK). This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications.
A young child is receiving treatment for lead poisoning. Which of the following is the most serious effect of long-term exposure to lead?
A. Impaired kidney function
B. Damage to the central nervous system
C. Anemia and fatigue
D. Lead colic and constipation
B
Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior, and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment.
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. The client asks about preconception diet changes. Which of these statements made by the nurse is the best approach in this situation?
A. "Increase your intake of green leafy vegetables."
B. "Eat at least one serving of fish weekly."
C. "Drink a glass of milk with each meal."
D. "Include fiber in your daily diet."
A
Folic acid sources should be included in the diet and are critical in the preconceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida.
The nurse is teaching a group of women in a community clinic about osteoporosis. Which explanation should the nurse include?
A. It is important to increase calcium intake and weight-bearing exercise.
B. Ice, rest and ibuprofen will help with the symptoms of osteoporosis.
C. Performing regular range-of-motion exercises will help with inflamed joints.
D. It is best to avoid foods high in purine, such as bacon, liver and shellfish.
A
Osteoporosis (OP) is a chronic, progressive metabolic bone disease marked by low bone mass and the deterioration of bone tissue, leading to bone fragility and an increased risk of fractures. Care focuses on proper nutrition, calcium supplementation, exercise, drugs and the prevention of falls.Osteoporosis is often mistaken for osteoarthritis (OA). Ice, rest, NSAIDs and range-of-motion exercises are used to treat symptoms of OA and/or Rheumatoid Arthritis (RA).Purine-rich foods need to be avoided with gout. Purine-rich foods increase uric acid production, which worsens the symptoms of gout.
The nurse works with children who have chronic conditions requiring frequent hospitalization and activity limitations. Which statement best describes the effects of immobility in children?
A. Children are more susceptible than adults to the multisystem effects of immobility
B. Immobility promotes independence and self-reliance in children
C. Immobilized children quickly develop confusion and mental status changes
D. The physical effects of immobility are similar in both children and adults
D
The physical effects of immobility are similar for clients of almost any age. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, constipation, bone demineralization, and cardiopulmonary complications. Immobility can negatively impact self-image and having to rely on others to meet their basic needs, especially in adolescents. Planning and providing nursing care in creative ways, and involving children in their care, and providing age-appropriate diversion can help reduce the effects of immobility. Older adults with chronic conditions are at greatest risk for developing confusion.
A client reports taking lithium as prescribed. Which of these findings indicate early signs of lithium toxicity?
A. Electrolyte imbalance, tinnitus and cardiac arrhythmias
B. Pruritus, rash and photosensitivity
C. Vomiting, diarrhea and lethargy
D. Ataxia, agnosia and course hand tremors
C
Serum lithium levels should be between 0.8 - 1.2 mEq/L (remember, the exact numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic finding at lithium levels below 2.0 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels.
The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment?
A. Dusky in color with poor skin turgor over abdomen
B. Pale skin, thin arms and legs, and uninterested in surroundings
C. Irritable and "colicky," making no attempts to turn or sit up
D. Alert, laughing, playing with a rattle, and sitting with support
B
Diagnosis of NOFTT is weight consistently below the 3rd to 5th percentile for age and gender, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of two major growth parameters in a short period of time. The nurse would expect to see a child who avoids eye contact, has pale skin, thin arms and legs, and is easily fatigued. NOFTT is due to psychosocial problems such as neglect, lack of knowledge about proper feeding or of the infant's needs. Many times the child engages in self-stimulatory behaviors (head banging or rocking) and is wary of close contact with people.
A client tells the nurse that the client is fearful of the planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
A. Deny the feelings
B. Call a chaplain
C. Listen to the client
D. Cite recovery statistics
C
Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, the nurse's acceptance of feelings should be followed by questions about the client's beliefs. [Show Less]