The nurse is coordinating care for a postpartum client and her newborn with the unlicensed assistive personnel (UAP). The mother is human immunodeficiency
... [Show More] virus (HIV) positive. The nurse would recognize the need to educate the UAP, who is observed doing which of the following actions?
A. Assist the mother who is attempting to breastfeed her baby
B. Place the infant on his or her back in the bassinet
C. Wear gloves while changing the newborn's soiled diaper
D. Assist the mother to walk to the bathroom
A
In the United States, it is current practice to counsel a mother who is HIV positive, or has AIDS, against breast feeding; breast feeding can transmit the virus through the breast milk to the infant. It is correct to place an infant on his or her back to prevent sudden infant death syndrome. Standard precautions should be followed when caring for any client; health care providers should wear gloves when they anticipate contact with body secretions (changing a soiled diaper).
The nurse is teaching a client about precautions while taking warfarin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient?
A. Calcium
B. Vitamin E
C. Iron
D. Vitamin K
D
Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive amounts of Vitamin K may alter anticoagulant effects. Foods highest in vitamin K include (dried and fresh) herbs, dark leafy greens, scallions, brussel sprouts, broccoli, chili powder, prunes, asparagus and cabbage.
A newly admitted client reports gaining 5 pounds (2.27 kg) the past week even though he has hasn't been very hungry. The nurse observes swelling of the feet and ankles. What is the most likely explanation for the weight gain?
A. Hyperthyroidism
B. Malnutrition
C. Congestive heart failure
D. Acromegaly
C
The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as little as two pounds (0.9 kg) in a week may require hospitalization due to worsening heart failure. The lack of appetite (or a feeling of being full) and edema are also signs of worsening heart failure. Hypothyroidism, and not hyperthyroidism, can lead to low body temperature, which causes fluid retention or bloating. Low protein levels in the blood caused by malnutrition can cause edema. However, there's not enough information given in the question to know if this client is malnourished or not. Acromegaly is characterized by overgrowth of body tissues, not edema, and is caused by excessive secretion of growth hormone.
A nurse is caring for a client with acute renal failure who has a subclavian vascular access port for hemodialysis. Which of these findings necessitates immediate action by the nurse?
A. Elevated temperature
B. Dry, hacking cough
C. Chronic fatigue
D. Pruritic rash
A
An elevated temperature in this client would indicate a possible central line infection. This finding should be reported to the provider who should order wound and blood cultures. If a line infection is suspected, the line will need to be removed, necessitating alternate line placement for hemodialysis. Interventions to prevention line infection through maintenance of line sterility and stabilization of the site are a priority in any client with a central line. The other findings should be reported to the health care provider but a febrile reaction is the priority.
The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two days. Which statement by the nurse provides the best nutritional information for the child?
A. Clear liquids and gelatin for 24 hours
B. NPO for 24 hours, then rehydrate with milk and water
C. Continue with the regular diet and include oral rehydration fluids
D. Offer bananas, apples, rice and toast as tolerated
C
Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and toast) diet may be appropriate.
An important goal in the development of a therapeutic inpatient milieu is which of these items?
A. Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions
B. Discourage expressions of anger because such feelings can be disruptive to other clients
C. Form a group forum in which clients decide on unit rules, regulations and policies
D. Offer a businesslike atmosphere where clients can work on individual goals
A
A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. The other approaches may be part of other types of therapies.
The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN) through a nasogastric tube. Which findings would indicate that the nurse needs to contact the health care provider? (Select all that apply.)
A. New onset adventitious lung sounds
B. 200 mL dark yellow urine voided in the last eight hours
C. Aspirated gastric fluid has a pH of 4
D. Pale and dry oral mucous membranes
E. A weight loss of 2 kg in 24 hours
F. Gastric residual volume of 100 mL
A,B,D,E
Pulmonary aspiration of enteral feeding formula is a risk for clients receiving EN. New onset adventitious or abnormal lung sounds on auscultation in a client receiving EN are indicative of fluid in a lung segment, or narrowing or obstruction of an airway. The health care provider should be notified.Throughout continuous EN, and before intermittent enteral feedings, it is imperative that aspirated secretions be tested for pH levels. In addition, routine aspiration precautions should include strict adherence to standard practices, such as residual volume checks, elevating the head of the bed during feedings and verification of tube exit location markings.Correct placement of the tube in the stomach is verified if the pH is lower than 5. If the tube has been inadvertently placed in a lung or the intestines, the aspirate pH is 6 or higher. Owing to the high risk of adverse events, finding a pH above 6 is a reason to stop the procedure and verify placement through radiologic methods. Aspirate pH may be altered because of medications or feedings (pH value from 4.5-6). If other indicators verify correct placement, waiting and retesting is recommended, rather than radiologic exposure.Delayed gastric emptying is a concern if 250 mL or more remains in a client's stomach (gastric residual volume (GRV)) on two consecutive assessments (one hour apart) or if a single GRV measurement exceeds 500 mL.Due to the nutrient-dense, hypertonic composition of enteral feeding formulas, clients on EN are at risk for developing hyperosmolar dehydration. Signs and symptoms of clinical dehydration include: sudden weight loss (overnight), postural hypotension, tachycardia, thready pulse, dry mucous membranes, poor skin turgor, slow vein filling, flat neck veins when supine and dark yellow urine. If the dehydration is severe, the symptoms will include thirst, restlessness, confusion, hypotension, oliguria (urine output below 30 mL/hr) and cold, clammy skin.
The client who is experiencing an acute asthmatic episode is admitted to the hospital with intermittent nonproductive coughing. The pulse oximeter reading is 88%. The client states to the nurse, "I feel like this is going to be a bad episode. I wish I would not have gone into that smoky bar last night." Which nursing diagnosis would be the priority for this client?
A. Anxiety related to hospitalization
B. Altered health maintenance related to preventative behaviors associated with asthma
C. Impaired gas exchange related to bronchoconstriction and mucosal edema
D. Ineffective airway clearance related to potential thick secretions
C
The low pulse oximetry reading indicates poor gas exchange, with inadequate oxygenation of arterial blood resulting from the bronchoconstriction and mucosal edema of the acute asthma attack. Treatments will include oxygen administration to correct the hypoxia, titrated to maintain a saturation at or above 92-95%, intravenous or oral corticosteroids to reduce the mucosal edema and inhaled bronchodilators such as albuterol via nebulizer or metered dose inhaler with a spacer to treat airway bronchoconstriction. While the other diagnoses may be appropriate for this client, they are not the priority at this time.
The nurse is caring for a client in labor. Which of the following situations will most likely put the neonate at risk for sepsis?
A. Premature rupture of membranes
B. Cesarean delivery
C. Precipitous vaginal birth
D. Maternal gestational diabetes
A
Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12 to 24 hours of leaking fluid, actions should be taken to reduce the risk of infection to the mother and the fetus/newborn.
A client is diagnosed with iron-deficiency anemia. What is the cause of the symptoms associated with this condition?
A. Decreased cardiac output
B. Reduced oxygen saturation
C. Destruction of red blood cells (RBCs)
D. Tissue hypoxia
D
Iron-deficiency anemia is when the RBCs are unusually small and pale (due to their low hemoglobin content.) Tissue hypoxia is the result of not having enough functioning hemoglobin in the blood to oxygenate the tissues; tissue hypoxia is responsible for symptoms such as fatigue, leg cramps and chewing ice. It's possible the client could have a normal SpO2 because the small amount of hemoglobin that's in the blood may be well saturated with oxygen. Anemia does not decrease cardiac output. Destruction of RBCs is associated with hemolytic anemia, not iron-deficiency anemia.
A nurse is taking a health history from a Native American client. It is critical that the nurse remember that eye contact with such clients is considered as which behavior?
A. Expected
B. Professional
C. Enjoyable
D. Rude
D
Native Americans consider direct eye contact to be impolite or aggressive among strangers.
The nurse is teaching a parent about side effects of routine immunizations. Which of these findings must be reported immediately?
A. Irritability
B. Local tenderness
C. Seizure activity
D. Slight edema at site
C
While severe complications are rare, any seizure activity must be immediately reported; seizures can occur up to 7 days after injection. Other reactions that should be reported include crying for more than three hours, temperature over 105 F (40.5 C) following DTaP immunization, and tender, swollen, reddened areas where the shot was given.
A child is to have chest physiotherapy (CPT) by the nurse. Which nursing action is appropriate?
A. Schedule the therapy 30 minutes after meals
B. Confine the percussion to the rib cage area
C. Teach the child not to cough during the treatment
D. Place the child in a prone position for the therapy
B
Percussion (clapping) should be done in the area of the rib cage anterior and posteriorly. The position depends on the desired outcome for secretion removal. This therapy should be done one hour prior or two hours after meals.
A nurse is providing instructions for a client with asthma who is allergic to house-dust mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
A. Wash bed linens in warm water with a cold rinse
B. Open the curtains to let the sunlight in each morning
C. Change the pillow covers every month
D. Wash and rinse the bed linens in hot water
D
For asthma clients who are allergic to house-dust mites, the mattresses and pillows should be encased in allergen-impermeable covers. All bed linens such as pillow cases, sheets and blankets should be washed and rinsed weekly in hot water at temperatures above 130 F (54.4 C), the temperature necessary to kill the dust mites.
The client is withdrawn. Which nursing intervention will be most effective to help the client develop relationship and interpersonal skills?
A. Offer the client frequent opportunities to interact with one person
B. Assist the client to analyze the meaning of the withdrawn behavior
C. Discuss with the client the focus that other clients have similar problems
D. Provide the client with frequent opportunities to interact with other clients
A
A withdrawn client is uncomfortable in social interaction. The nurse-client or a one-on-one relationship is a corrective relationship in which the client learns tolerance and skills for relationships.
A nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir for a herpes simplex virus type 2 infection. Which of these instructions should the nurse give the client?
A. Continue to take prophylactic doses for at least five years after the diagnosis
B. Complete the entire course of the medication for an effective cure
C. Begin treatment with acyclovir at the onset of symptoms of recurrence
D. Stop treatment if she thinks she may be pregnant to prevent birth defects
C
When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease. They simply decrease the intensity of the symptoms. Acyclovir (Zovirax) is not known to have an impact on the fetus. Acyclovir should not be taken for preventive purposes, regardless of the date of diagnosis.
A licensed practice nurse (LPN) from the float pool is sent to an adult medical-surgical unit. With this newly added staff person, the charge nurse needs to revise assignments for the shift. Which of the following clients are appropriate to assign to the float pool LPN?
A. An older client with newly diagnosed type 2 diabetes and a client who is HIV-positive with a diagnosis of pneumonia
B. A trauma victim newly admitted with a diagnosis of quadriplegia and a client one day postoperative radical neck dissection
C. A young adult client with a history of schizophrenia and with current alcohol withdrawal syndrome and a client diagnosed with chronic renal failure and anemia
D. A middle-aged client diagnosed with hemiplegia and with a gastrostomy tube and a client with a below-the-knee amputation (BKA) who will be starting physical therapy
D
The client diagnosed with hemiplegia (and a gastrostomy tube) and the client who is starting physical therapy following a BKA require supportive care and interventions that are within the scope of practice of a LPN. These clients are the most stable and have a minimal risk of complications. The clients in the other options require RN care. Some of the clues are: "newly admitted," "newly diagnosed" and "current alcohol withdrawal" - each of these clients have a high risk of instability and/or require the specialized nursing knowledge, skill or judgment of a registered nurse.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should follow which of the following guidelines?
A. Sodium-restricted
B. High-fat, high-calorie foods
C. Skim milk and low-fat dairy products
D. Restricted calorie
B
The child with cystic fibrosis requires a well-balanced diet that is high in calories (approximately 2,900 to 4,500 calories a day). The diet should include increased amounts of protein, iron, salt, zinc and calcium (especially full-fat dairy products.) Fat does not need to be restricted because these children lose fat in the stool. Recall one of the characteristics of this disease is fatty, foul smelling stool.
A child with tetralogy of Fallot visits the clinic several weeks before the scheduled surgery. The nurse should give priority attention to which focus?
A. Observation for developmental delays
B. Prevention of infection
C. Maintenance of adequate nutrition
D. Assessment of oxygenation
D
All of the responses would be important for a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis, which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and may result in neurological complications.
A nurse is caring for a 69-year-old diagnosed with hyperglycemia. Which activity or task could be assigned to the unlicensed assistive person (UAP)?
A. Review the initial signs of hyperglycemia with the client's family
B. Check the condition of the skin of the lower extremities
C. Monitor for altered levels of consciousness (LOC)
D. Record dietary intake
D [Show Less]