Physiological Health Problems (10) – Flashcards
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A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items:
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B. Within the client's reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client's personal care items are placed within the client's reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client's environment to the deficit by focusing on the client's unaffected side and by placing the client's personal care items on the affected side within reach. Placing items out of the client's reach presents a risk of injury.
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The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply.
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E. Crackles on auscultation of the lungs. Rationale: Signs of left-sided heart failure result from decreased cardiac output and increased pulmonary venous congestion, and the nurse would note signs related to the respiratory system, such as cough, dyspnea, and crackles and wheezes on auscultation of the lungs. Right-sided heart failure is associated with increased systemic venous pressure and congestion, and the nurse would note signs such as neck vein distention, dependent edema, abdominal distention, and weight gain.
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A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction?
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A. "I should put a steam vaporizer in her room." Rationale: Steam from running water in a closed bathroom and cool mist from a bedside humidifier or a freezer are effective in reducing mucosal edema. A cool mist humidifier is recommended over a steam vaporizer, which presents a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling.
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A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother:
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B.To bring the newborn to the clinic. Rationale: Symptoms of cord infection include moistness, oozing, discharge, swelling, and a reddened base. If symptoms of infection occur, the newborn must be seen by the healthcare provider. Telling the mother to increase the number of times that the cord is cleansed each day or to place an ice pack on the umbilical cord site and stating that this is a normal occurrence are inappropriate nursing interventions.
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The wife of a client with angina pectoris calls the physician's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client's wife to:
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D. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED. Rationale: Chest pain that is unrelieved by rest and three doses of nitroglycerin taken 5 minutes apart may be not typical anginal pain but instead a sign of myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the 24 hours after MI, it is imperative that the client receive emergency cardiac care. If the client needs to go to the ED, the nurse must instruct the client's wife to call an ambulance to transport her husband. The client's wife must not drive the client, because the client should not exert energy and place an increased workload on the heart and the client's wife would not be able to provide care if an emergency arose during transport to the hospital. Telling the wife that she will have to discuss the situation with the physician, who will call her as soon as he gets to his office, delays necessary interventions. Having her husband rest delays necessary interventions; also, the usual procedure is to have the client take three nitroglycerin tablets before seeking medical attention.
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Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that:
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D. Moist heat will increase circulation and may be used before the breasts are emptied. Rationale: Antibiotic therapy and continued decompression of the breasts, by means of breastfeeding or with a breast pump, is prescribed for the client with mastitis. In most cases the mother may continue to feed with both breasts. If the affected breast is too sore, the mother may pump the breast gently. Regular emptying of the breast is important in preventing abscess formation. Antibiotic therapy helps resolve mastitis within 24 to 48 hours. Additional supportive measures include moist heat or ice packs, breast support, and analgesics. Moist heat promotes comfort and increases circulation. A shower or hot packs should be used before the breasts are emptied or before feeding.
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A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition?
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A. Trace protein in the urine. Rationale: Preeclampsia is considered mild when the systolic blood pressure is 140 mm Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick, and symptoms such as headache, visual disturbances, and abdominal pain are absent. In addition, signs of kidney or liver involvement are absent. An increased BUN level indicates kidney damage, a result of the preeclampsia.
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A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child's condition:
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C. Indicates deterioration in neurological function. Rationale: In decorticate posturing, the upper extremities are flexed and the lower extremities are extended. In decerebrate posturing, the upper and lower extremities are extended and the upper arms and wrists and the knees and feet are internally rotated. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification. The remaining options are inaccurate interpretations.
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During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client:
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C. That the intraocular pressure in both eyes is normal. Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore this client's intraocular pressure is normal. Increased intake of fluids is unrelated to increasing intraocular pressure.
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A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction?
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B."I should lie on my right side in bed." Rationale: Positions that will help the client with COPD breathe more freely include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, sitting up in a chair, and standing and leaning against the wall. These positions allow for the greatest expansion of the lungs and respiratory cage in all directions. Lying on the side is not effective.
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A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client?
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B. Avoid rapidly moving the head and bending over for at least 3 weeks. Rationale: The client must avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks to prevent disruption of the surgical site. The client should keep the affected ear dry at all times and should avoid getting the head wet, washing the hair, or showering for 1 week. The client should not rinse out the ear. The client also needs to avoid drinking through a straw for 2 to 3 weeks because the sucking action necessary to use the straw could cause disruption of the surgical site. The client should notify the physician if excessive ear drainage is noted.
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A nurse is providing instructions to a nursing assistant about effective measures for communicating with a hearing-impaired client. The nurse instructs the nursing assistant to:
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D. Face the client when talking, keeping the hands away from the mouth. Rationale: To facilitate communication with a client who is hearing impaired, the nurse should speak in a normal tone, not shout or raise the voice. The nurse should speak clearly and directly while facing the client and keep the hands away from the mouth so that the client can read the nurse's lips. It may be helpful for the nurse to move closer to the client and toward the better ear to facilitate communication, but it is not helpful to talk directly into the client's impaired ear. Smiling while talking will make it difficult for the client to lipread.
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A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to:
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D. Eat small frequent meals that are low in fat and protein and high in carbohydrates. Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce metabolic demand on the liver and increase its blood supply, but strict bed rest is unnecessary. The client should avoid taking medications, including acetaminophen (which is hepatotoxic), unless they are prescribed by the healthcare provider. The client must avoid all alcohol consumption. The client should consume small frequent meals that are low in fat and protein and high in carbohydrates to reduce the workload of the liver.
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A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately:
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B. Assesses the client. Rationale: If a monitor alarm sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. Asystole should not be mistaken for an unattached electrocardiogram wire. If the client is alert and the client's status is stable, the problem is likely an unattached cardiac lead or wire. Calling a code and obtaining a rhythm strip from the monitor device are unnecessary if the client's condition is stable.
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A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply.
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B.Severe chest pain C. Absence of fetal heart tones. Rationale: Signs of uterine rupture vary with the degree of rupture. Signs and symptoms include abdominal pain and tenderness, chest pain, hypovolemic shock, signs associated with impaired fetal oxygenation, an absence of fetal heart tones, cessation of uterine contractions, and palpation of the fetus outside the uterus if the rupture is complete. Signs of hypovolemic shock include tachycardia; tachypnea; pallor; cool, clammy skin; and anxiety.
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A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction?
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D. "I can dry the cast faster if I use a hairdryer on the hot setting." Rationale: Using a blow dryer on the hot setting to dry the cast is not advised because it may burn the client's skin under the cast and crack the cast. While the cast is still damp, the client may feel cold and may experience a decrease in body temperature. The client should never insert any item under the cast because of the risk skin compromise. An odor coming from the cast could indicate the presence of infection, warranting physician notification.
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A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication?
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D.Ensure that the medication is diluted in an appropriate amount of normal saline solution. Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The physician is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line.
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A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan?
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A.Visitors must be limited to one half-hour per day. Rationale: The nurse would limit each visitor to a half-hour per day and be sure that visitors remain at least 6 feet from the radiation source. The nurse would wear the dosimeter badge when caring for the client. The dosimeter badge measures an individual's exposure to radiation and should be used by only one individual. The dosimeter badge is not left in the client's room. The client is assigned to a private room with a private bath to keep other clients from being exposed to radiation.
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The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct?
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D. 30:2 Rationale: A 30:2 ratio of compressions to ventilations is recommended for CPR in adults. The other options are incorrect.
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A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion?
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D. Limiting elevation of the head of the bed to 45 degrees. Rationale: To prevent graft occlusion, the nurse limits elevation of the head of the bed to 45 degrees. The nurse does assess the client for signs of graft occlusion, but assessment will not prevent occlusion. The signs of graft occlusion include changes in peripheral pulses, cool-to-cold extremities distal to the graft, white or blue extremities or flanks, severe pain, and abdominal distention. Bowel sounds and urine output are also assessed, but these parameters are unrelated to graft occlusion.
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A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation?
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D. Nonproductive cough. Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
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A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which of the following questions does the nurse plan to include?
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A. Call the physician if the infant is lethargic. Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which causes the infant to make a high-pitched cry or induces changes in level of consciousness, such as lethargy. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urine output is not expected. The anterior fontanel normally bulges when the infant cries.
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The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction?
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B. "I can use over-the-counter cortisone cream on the radiation site if it gets red." Rationale: The client should use no powders, ointments, lotions, or creams on the skin at the radiation site unless they have been prescribed by the physician. Avoiding sun exposure of the radiation site, not removing marks made on the skin by the radiologist, and washing the skin with mild soap and water and patting it dry are all correct measures. The client should also be instructed to avoid using harsh detergents to wash clothing.
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A nurse is working in the emergency department. Which of the following clients should be assessed first?
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D. A client with new-onset atrial fibrillation with a rate of 118 beats/min. Rationale: The client with new-onset atrial fibrillation is at risk for complications associated with the tachydysrhythmia. This dysrhythmia may result in decreased cardiac output because of ineffective atrial contractions. Thrombi form in the atria as a result of the pooling of blood. All of the other clients will require the nurse's attention, but the client who requires immediate attention and is the most hemodynamically unstable is the one with atrial fibrillation.
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A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will:
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D. Expect to experience pain, nausea, and vomiting after the procedure. Rationale: If the client experiences any pain that is unrelieved, redness around the eye, or nausea or vomiting, the physician must be notified, because such findings could be an indication of increased intraocular pressure. Usually the client is given a follow-up appointment on the day after the surgery, and the physician removes the eye patch at this time. The client is instructed to limit activity to sitting in a chair, resting, and walking to the bathroom for 24 hours. Aspirin or medications containing aspirin should not be taken by the client; rather, acetaminophen (Tylenol) should be used to alleviate discomfort.
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A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first?
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A. Assessing the client's vision. Rationale: When a client has sustained a surface injury of the eye as a result of the introduction of a foreign body, the nurse must first assess visual acuity. The eye is then assessed for corneal abrasions; this is followed by irrigation with sterile normal saline solution to gently remove the particles. Ice would be placed on the eye if the client had sustained an eye contusion.
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A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse?
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D. Antecubital fossa of the arm. Rationale: An infant's pulse should be checked at the brachial artery. The relatively short, fat neck of an infant makes palpation of the carotid artery (neck) difficult. Palpation of the pulse in the radial (wrist) and popliteal (behind the knee) area would also be difficult.
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An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client?
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C. With the knees drawn up to the chest. Rationale: Helping the client assume the fetal position (legs drawn up to the chest) will ease the abdominal pain of pancreatitis. Other helpful positions include sitting up, leaning forward, and flexing the legs (especially the left leg). Prone, supine with the legs straight, and side-lying with the head of the bed flat are incorrect.
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A client with chronic renal failure is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client?
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B. Headache and confusion. Rationale: Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, confusion, decreasing level of consciousness, nausea, vomiting, twitching, and, in some cases, seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a higher residual concentration gradient in the brain, caused by the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented with the use of shorter dialysis times or dialysis at a reduced blood flow rate. Irritability and generalized weakness, fever and tachycardia, and bradycardia and hypothermia are not associated with disequilibrium syndrome.
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A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside?
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B. Sterile dressing. Rationale: The newborn with spina bifida is at risk for infection before the closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin at the site. A flashlight may be needed to closely assess the status of the gibbus but is not a priority item. A cardiac monitor is not necessary. Blood pressure is difficult to assess during the newborn period and is not the best indicator of infection. The blood pressure cuff would not be a priority item.
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A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm?
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D.Ventricular tachycardia. Rationale: Ventricular tachycardia is characterized by a ventricular rate of 100 to 250 times/min. There is a wide QRS complex and an absence of P waves. The rhythm is usually fairly regular. In atrial fibrillation, multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350 to 600 times/min. The atria quiver, which can lead to the formation of thrombi. No definitive P wave is observed, only fibrillatory waves before each QRS. Sinus tachycardia is characterized by a normal sinus rhythm that is rapid (faster than normal) in rate. Sinus bradycardia is characterized by a rhythm that is slower than normal.
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A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which of the following clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply.
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B.Muscle weakness C. Increased urine output Rationale: Signs of hypercalcemia include muscle weakness, diminished deep tendon reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the Chvostek sign, and paresthesias are signs of hypocalcemia.
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A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which of the following findings would the nurse expect to note?
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A.Hypertension. Rationale: Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration.
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A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease?
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D. "Has he had a sore throat in the last few months?" Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. The nurse first determines whether the child had a sore throat or an unexplained fever within the past 2 months. Asking the parents whether the child has had any loss of appetite, complained of backache recently, or been excessively tired or lethargic will elicit information unrelated to rheumatic fever.
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A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to:
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A. Limit sodium in the diet. Rationale: Limiting and fluids in the diet will help reduce the amount of endolymphatic fluid, which is excessive in Ménière disease. The client's room should be darkened to reduce the acute symptoms of vertigo. The client should limit head movement to prevent worsening of the symptoms of vertigo.
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A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first?
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D. Using long-handled forceps to place the implant in a lead container. Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant is dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. Reinserting the implant into the vagina and picking up the implant with gloved hands and placing it in sterile water are both incorrect nursing actions. The physician is called after action is taken to maintain the safety of the client.
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An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will:
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B. Have her child use a straw to make drinking easier. Rationale: Introduction of a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Citrus fruits are avoided because they could irritate the throat. Acetaminophen is used for pain relief. A foul mouth odor is normal and can be relieved by drinking fluids.
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A client is found to have AIDS. What is the nurse's highest priority in providing care to this client?
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C. Instituting measures to prevent infection in the client. Rationale: The client with AIDS has inadequate immune bodies and is at risk for infection. The priority nursing intervention is protecting the client from infection. The nurse would also provide emotional support to the client. Discussing the cause of AIDS and the ways in which AIDS is contracted are not priority interventions.
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A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then:
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A.Prepares for reintubation. Rationale: If unexpected extubation occurs, the nurse must first assess the client for airway patency and spontaneous breathing. The nurse remains with the client, calls for assistance, and prepares for reintubation. The rapid response team is called when there is a change in the client's status in a hospital area outside the ICU. The nurse would not administer an antianxiety medication, because this could affect the client's breathing. The nurse would not restrain the client, because restraints could increase the client's anxiety.
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A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate?
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A. Contacting the physician. Rationale: Some hematuria is normal for several days after transurethral resection of the prostate. If bright-red bleeding occurs, the physician needs to be notified, particularly if the client exhibits a change in vital signs. These findings are a potential sign of excessive blood loss and the need for emergency surgical intervention. Continuing to monitor the client delays necessary interventions. The nurse would not increase the rate of flow of an IV without a physician's order. Placing pressure on the bladder to aid expulsion of any additional clots is an inappropriate and unsafe action that could worsen the bleeding.
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A nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beats does the nurse recognize?
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D.Premature ventricular contractions (PVCs). Rationale: PVCs are labeled as premature because they occur early in relation to the timing of previous normal beats. They have no visible P wave and have a characteristically wide and bizarre QRS complex. There is a compensatory pause. These ectopic beats are generally easy to recognize on the electrocardiogram (ECG). When every other beat is a PVC, the rhythm is called ventricular bigeminy. When every third beat is a PVC, it is called trigeminy. Sinus bradycardia is characterized by a normal sinus rhythm, but the rate is slower than normal. Ventricular fibrillation is the result of chaos in the ventricles. Impulses from many irritable foci fire in a totally disorganized manner, preventing ventricular contraction. There are no recognizable deflections. Ventricular tachycardia occurs because of a repetitive firing of an irritable ventricular ectopic focus at a rate of 140 to 250 tines/min or more; it may present as a paroxysm of three self-limiting beats or more or may be a sustained rhythm.
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A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves:
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D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material. Rationale: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material.
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A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the following foods does the nurse tell the mother to include in the child's diet?
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A. Rice. Rationale: Dietary management is the mainstay of treatment in celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. Dietary restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the ulcerations have healed.
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A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to:
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B. Rock back and forth to start movement. Rationale: The client with Parkinson disease should rock back and forth to initiate movement with bradykinesia (slowed movement). The client should avoid sitting in soft, deep chairs to prevent rigidity and because they are difficult to get up from. The client should exercise in the morning, when the energy level at its highest. The client with a tremor is instructed to use both hands to accomplish a task.
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A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately:
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A. Records the findings. Rationale: In the postpartum period, the nurse assesses for uterine atony and checks the consistency and location of the uterine fundus. The uterine fundus should be firmly contracted, at or near the level of the umbilicus, and midline. Therefore the nurse would record the findings. Because the finding is normal, massaging the fundus, contacting the physician, and assisting the mother to void are not necessary. The nurse would massage the uterine fundus if it were soft and boggy. The physician would be contacted if the client were to experience excessive bleeding. A full bladder could cause a displaced fundus and one that is above the level of the umbilicus.
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A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:
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C. "I don't need medication unless I'm having a severe attack." Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease.
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A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately:
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C. Places the client in the knee-chest position. Rationale: When cord prolapse occurs, prompt action is taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Such positions include knee-chest, Trendelenburg, and the hips elevated on pillows with the client in a side-lying position. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it, because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by way of facemask is administered to the mother to increase fetal oxygenation. A tocolytic medication is administered to inhibit contractions on the order of the physician, and the client is quickly prepared for delivery, but these are not the actions that would be taken immediately.
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A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately:
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C. Checks the client's bladder for distention. Rationale: Autonomic dysreflexia is an emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A variety of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse then performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately by way of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or compromise. The physician is notified, and then the nurse documents the occurrence and the actions taken.
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A client who is recovering from a brain attack (stroke) has residual dysphagia. Which of the following measures does the nurse plan to implement at mealtimes?
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B. Alternating liquids with solids. Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to help prevent aspiration. Food is placed on the unaffected side of the mouth. Liquids are alternated with solids whenever possible to prevent food from being left in the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.
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The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately:
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D. Begins cardiopulmonary resuscitation (CPR). Rationale: Ventricular fibrillation is the result of chaos in the ventricles. Impulses from many irritable foci fire in a totally disorganized manner, preventing ventricular contraction. There are no recognizable deflections. The goals of treatment are to terminate the ventricular fibrillation promptly and to convert it to an organized rhythm by means of defibrillation. The nurse would immediately begin CPR and continue it until a defibrillator arrived. Because the nurse has already noted that the client is unconscious, assessing the client's neurological status is incorrect. Increasing the flow rate of the oxygen and increasing the flow rate of the client's IV infusion will not provide the support needed in this emergency. CPR guidelines recommend CAB - circulation, airway, and breathing. If the nurse checks for a pulse, it should be a carotid pulse, not a radial pulse.
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A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective?
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B. Blood pressure and weight. Rationale: After hemodialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable and for comparison with predialysis measurements. The client's blood pressure and weight are expected to be reduced as a result of fluid removal. Laboratory studies are performed as per protocol but are not necessarily done after the hemodialysis treatment has ended.
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A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction?
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D. "I'll put lotion on my leg a few times a day." Rationale: The client should be instructed to don the prosthesis immediately on arising and to keep it on all day (once the incision has healed completely) to reduce residual limb swelling. "I can wash my leg with a mild soap," "I need to check my leg for irritation every day," and "I should wear a sock over my stump" are correct statements regarding residual limb and prosthesis care. The client should not use any lotions, alcohol-containing powders, or oils on the residual limb unless told to do so by the healthcare provider. The client should also perform range-of-motion exercises of the joints, as well as strengthening exercises, including the upper extremities, every day.
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A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request?
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B. "You need to stay in your room for now." Rationale: The client with a sealed radiation implant must remain in a private room to keep others from being exposed to radiation. The other options are all incorrect.
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A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child?
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A. Lethargy. Rationale: Clinical manifestations of iron-deficiency anemia vary with the degree of anemia but usually include extreme pallor with porcelainlike skin, tachycardia, lethargy, and irritability.
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A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?
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C. Palpate for a vibrating sensation at the fistula site. Rationale: An arteriovenous fistula is created in a surgical procedure in which an anastomosis is created between an artery and a vein in the arm in an end-to-side, side-to-side, side-to-end, or end-to-end fashion. In a patent fistula (or graft), a "thrill," or vibrating sensation, should be palpable and a bruit should be audible with a stethoscope. An arteriovenous fistula is the client's lifeline, and the nurse does not irrigate or infuse solutions into it. It is used only for hemodialysis.
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The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states:
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B. "I should sleep flat on my right side." Rationale: A side-lying position with head of the bed elevated is most likely to prevent reflux while sleeping. A flat position will increase reflux. The client is instructed to avoid eating in the 3 hours before bedtime because a full stomach may also cause reflux. Antacids and histamine antagonists may be prescribed for the client.
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A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child:
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D. ½ cup of fruit juice. Rationale: Hypoglycemia is immediately treated with 15 g of carbohydrate. Glucose tablets or glucose gel may be administered. Other items used to treat hypoglycemia include ½ cup of fruit juice, ½ cup of a regular (nondiet) soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes of sugar or 4 tsp of sugar, 6 saltines, 3 graham crackers, and 1 tablespoon of honey or syrup. One sugar cube, a teaspoon of sugar, or ½ cup of diet cola would not be adequately treatment for hypoglycemia.
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A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next?
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A.Use the AED. Rationale: Basic components of CPR include immediate recognition of the sudden cardiac arrest (unresponsiveness and absence of normal breathing) and activation of the emergency response system, early CPR, and rapid defibrillation with the use of an AED.
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A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction?
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C. "I should avoid all exercise when my joints are inflamed." Rationale: The client should avoid activities (other than gentle range of motion) when the joints are inflamed. Isometric exercises are also helpful when the joints are inflamed. Daily range-of-motion exercises are an important component of the program and will help relieve pain, but the client should exercise only to the point of fatigue or discomfort. All clients are taught to maintain good posture.
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A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for:
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D. Signs of congestive heart failure (CHF). Rationale: Kawasaki disease is an acute systemic vasculitis that primarily affects the cardiovascular system. The subacute phase is characterized by continued irritability, anorexia, desquamation of the fingers and toes, arthritis and arthralgia, and cardiovascular manifestations, including CHF. Nursing care is focused on observation of the child for signs of CHF. The nurse is alert for an increased respiratory rate, increased heart rate, dyspnea, congestion and crackles, and abdominal distention. Bleeding, a high fever, and failure to thrive are not directly associated with this disorder. In the subacute phase, the fever subsides.
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A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect?
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D. Dysphagia. Rationale: In general, skin reactions and fatigue may occur with radiation therapy of any site, whereas other side effects occur only when a specific area lies in the treatment field. A client undergoing radiation therapy of the larynx is most likely to experience dysphagia. Diarrhea may occur with irradiation of the gastrointestinal tract. Dyspnea may occur with lung irradiation. Headache may occur with irradiation of the head.
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A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am-7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume?
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C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr. Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume.
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A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record?
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B. Positive result on an acid-fast bacillus smear. Rationale: A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis (acid-fast bacillus), which is the organism responsible for the disease. The initial testing involves microscopic examination of stained sputum smears for acid-fast bacilli (a.k.a. the ABF test). In the tuberculin skin test, or Mantoux test, 0.1 mL of purified protein derivative (PPD) is injected intradermally on the dorsal surface of the forearm. The injection site is then assessed in 48 to 72 hours for the presence of an induration. In low-risk individuals (e.g., those who are not immunocompromised), an area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection indicates exposure to and infection with TB. Night sweats, a low-grade fever, cough, and mucopurulent sputum are clinical manifestations of TB but do not confirm the diagnosis.
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A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. The nurse advises the child's mother to immediately:
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C. Apply ice to the affected eye. Rationale: Treatment for a contusion ideally begins at the time of injury and includes the application of ice to the site. Although the child should also undergo a thorough eye examination to rule out other injuries, calling an optometrist is not the first action to be taken. Irrigating the eye with cool water may be implemented for injuries that involve a splash of an irritant into the eye. It is not necessary to call an ambulance.
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A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding?
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A. 3.1 mEq/L. Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia.
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A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client:
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D. That redness and swelling of the eyelids and conjunctiva are expected. Rationale: The scleral buckling procedure is performed to treat retinal detachment. In the preoperative period the nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may require bilateral patching. Redness and swelling of the eyelids and conjunctiva, the result of surgical manipulation, are expected. Blood loss in retinal detachment surgery is minimal, and only serous drainage is expected on the postoperative dressing. The client should not expect immediate return of vision. Postoperative inflammation and eye drops interfere with vision. Because healing takes place over weeks to months, vision will improve gradually. Strict bedrest for 48 hours is not required; however, depending on the location and size of the retinal break, activity restrictions may be needed to prevent further tearing or detachment and to promote drainage of any subretinal fluid.
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A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to:
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B. Take the prescribed insulin dose even if he is unable to eat. Rationale: Insulin should never be independently stopped or decreased, and the client is instructed to take prescribed insulin even if he or she is vomiting or unable to eat. Acute illness may cause a counterregulatory hormone response, resulting in hyperglycemia. During times of illness, the client should monitor the blood glucose level and notify the physician if it exceeds 250 mg/dL. Adequate fluids and carbohydrates are essential during illness. The client should eat 10 to 15 g of carbohydrate every 1 to 2 hours and drink a small quantity of fluid every 15 to 30 minutes to help prevent dehydration and ketoacidosis. The client should notify the physician of a fever over 100° F.
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A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first?
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A. Beginning chest compressions. Rationale: According to the American Heart Association, detecting a pulse may be difficult. The healthcare provider should take not more than 10 seconds to check for a pulse; if the rescuer does not definitely feel a pulse within that period, he or she should start chest compressions. The acronym CAB (circulation, airway, and breathing) is used to prioritize the steps of cardiopulmonary resuscitation (CPR). Effective chest compressions are essential for providing blood flow during CPR. To provide effective chest compressions, the provider must push hard and fast. Current guidelines for CPR call for the initiation of compressions before ventilations. Oxygen may be helpful at some point, but the airway is opened before the administration of oxygen. Checking the client's pulse oximetry reading delays implementation of lifesaving measures.
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A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which sign of DVT, the most common, does the nurse assess the client?
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D. Pleuritic chest pain. Rationale: Pulmonary embolism is a life-threatening complication of thrombophlebitis or DVT. Pleuritic chest pain, the most common clinical manifestation, occurs suddenly and is worsened by breathing. Other signs and symptoms include shortness of breath and dyspnea, diaphoresis, and apprehension. Cough is also a manifestation but is not a common sign.
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A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved?
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D. Weight loss of 4 lb in 24 hours. Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved.
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A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which of the following findings would the nurse expect to note in the event of an ischemic episode?
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B. ST-segment depression. Rationale: An ECG taken in the presence of pain may reveal ischemic changes with ST-segment elevation or depression. Peaked T waves may indicate hyperkalemia. PVCs are caused by the firing of an irritable pacemaker in the ventricle. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block.
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A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which of the following findings does the nurse monitor the neonate most closely?
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D. Respiratory distress syndrome. Rationale: The major neonatal complications of preexisting diabetes mellitus in the mother are hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant, which is needed to keep the alveoli open after birth.
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A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately:
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B. Contacts the physician. Rationale: In the immediate postoperative period, the nurse assesses the client for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea), a sign of airway edema, and for signs of bleeding. A drop in blood pressure and an increase in pulse are indicators of bleeding. The physician is notified immediately if either of these events occurs. Suctioning is performed to remove secretions that cannot be expectorated by the client. Increasing the rate of the client's IV solution is not done without a physician's prescription. A pulse oximeter may be needed, but this is not the action to be taken immediately.
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A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately:
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C. Places the infant in the knee-chest position. Rationale: If a hypercyanotic episode occurs, the infant is calmed and placed in the knee-chest position, and the physician is notified. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to achieve this position and relieve chronic hypoxia. Oxygen is also administered to the infant.
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A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first:
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C. Attaches the child to a pulse oximeter. Rationale: To adequately determine whether the child is getting enough oxygen, the nurse attaches the child to a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately attached to a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. Next the nurse performs an assessment, including the child's temperature and weight, and asks the parents about the child. An antibiotic may be prescribed, but the child's airway status must be assessed first.
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A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which of these statements by the mother indicate a need for further instructions? Select all that apply.
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A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him." Rationale: Hemophilia is the term given to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Identifying the specific coagulation deficiency is important because it allows definitive treatment with the specific replacement agent to be implemented; aggressive replacement therapy is initiated to prevent the chronic crippling effects of joint bleeding. The child does not outgrow the disorder, and lifetime management is needed. The nurse must stress the importance of immunizations, dental hygiene, and routine well-child care for the child with hemophilia. The remaining statements represent appropriate care measures.
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A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment?
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C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema. Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority.
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A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver?
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D. 100. Rationale: In an infant or child, the rate of chest compressions is at least 100/min.
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Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care?
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D. Checking the skin integrity of the right leg at least every 8 hours. Rationale: Buck extension traction is a type of skin traction. It is important with skin traction to inspect the skin underneath at least once every 8 hours for irritation or inflammation. The nurse never releases the weights of traction unless specifically asked to do so by the physician. Applying lanolin to the skin could leave the skin slippery, making it difficult to maintain the belt or boot used for the skin traction. There are no pins to care for with skin traction.
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A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply.
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B. Decreased urine output D. Increased respiratory rate. Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload.
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A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client?
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A. An ultrasound examination. Rationale: A manual pelvic examination or any action that would stimulate uterine activity is contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is therefore contraindicated.
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A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first?
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C. Check the system for kinks. Rationale: If outflow drainage is inadequate, the nurse must first check the system for kinks. If there are no kinks in the system, the nurse should change the client's position to shift abdominal fluid. The catheter should not be irrigated. Hanging the next exchange and continuing to monitor outflow will not alleviate the problem.
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A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn?
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C. Short palpebral fissures and a flat midface. Rationale: Fetal alcohol syndrome (FAS) is characterized by recognizable facial anomalies, prenatal and postnatal growth restriction, and central nervous system impairment. The common facial anomalies include short palpebral fissures (the openings between the eyelids), a flat midface, an indistinct philtrum (median groove on the external surface of the upper lip), and a thin upper lip.
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A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to:
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C. Turn the head to scan the lost visual field. Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision, but it is not necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision.
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A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately:
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A. Contacts the client's physician. Rationale: Preeclampsia is dangerous to the woman and fetus because it can progress rapidly, and the earliest manifestations may go unnoticed by the woman. Some symptoms, such as epigastric pain and upset stomach, are particularly ominous because they indicate distention of the hepatic capsule and often mean that a seizure is imminent. Therefore telling the client to avoid lying flat position, instructing the client to eat a small portion of food every 2 to 3 hours, and administering an antacid and telling the client to take a dose every 6 hours are all incorrect. Additionally, the nurse would not administer an antacid to the pregnant client without a prescription to do so.
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A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse tells the client:
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A. To plan to drain the reservoir every 2 to 3 hours initially. Rationale: An Indiana pouch is a continent internal ileal reservoir, and the nurse instructs the client in the technique of catheterization. Initially the client drains the reservoir every 2 to 3 hours. Each week thereafter, the interval is increased by 1 hour until finally catheterization is completed every 4 to 6 hours during the day. The catheter is never forced into the reservoir. If resistance is met, the client is instructed to pause and apply only gentle pressure while slightly rotating the catheter. A 16F to 20F catheter is used; 26F is too large and could damage the reservoir. Mucus is expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of normal saline solution to prevent excessive mucus buildup.
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A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented?
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A. Uterine tenderness. Rationale: In abruptio placentae, abdominal pain and uterine tenderness are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation because the blood penetrates the myometrium, resulting in uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. Constipation is not associated with this disorder.
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A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which of the following assessment findings indicates to the nurse that the client may be experiencing hypotonic contractions?
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D. Contractions that can be indented easily with fingertip pressure at their peak. Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.
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A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the client with:
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C. Addison disease. Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the finding to the physician. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia.
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A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mg/dL. Which assessment findings does the nurse expect to note? Select all that apply.
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B. Abdominal distention C. Trousseau sign. Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL reflects hypomagnesemia. Assessment signs include hypertension; gastrointestinal manifestations such as anorexia, nausea, abdominal distention, and decreased bowel sounds; shallow respirations; neuromuscular manifestations such as twitches, paresthesias, hyperreflexia, and the Trousseau and Chvostek signs; and irritability and confusion.
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A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist?
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D. The traction ropes are unable to move over the pulleys. Rationale: After skeletal traction pins are inserted and traction is applied, all ropes, knots, and pulleys are inspected to ensure that they are positioned properly. Traction knots and ropes must be intact and secure. Ropes should move easily over pulleys and weights, and the weights should hang freely at all times. The clamps on the traction frame should be tight.
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A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first:
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D. Manually ventilate the client, using a resuscitation bag. Rationale: Because the client is experiencing respiratory distress, the client should be manually ventilated with the use of a resuscitation bag until the problem can be determined. Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Such alarms must be activated and functional at all times. The low exhaled volume alarm sounds when there is a disconnection or leak in the ventilator circuit or a leak in the client's artificial airway cuff. A code is called when the client requires resuscitation. An anesthesiologist may be needed to insert an endotracheal tube or to assist with a code. Accumulation of secretions in the respiratory system and the need for suctioning would trigger the high-pressure alarm.
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A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?
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B. Semi-Fowler. Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are all incorrect because they will result in increased edema at the site.
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A client arrives at the emergency department with complaints of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first?
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D. Administration of a subcutaneous injection of epinephrine (Adrenalin). Rationale: Once airway has been established, the client would be given subcutaneous epinephrine. IV corticosteroids and IV fluids may also be prescribed. Pain medication may or may not be prescribed.
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A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which of the following occurrences does the nurse expect the mother to report?
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D. Bloody mucus stools and diarrhea. Rationale: In the child with intussusception, bloody mucus stools, commonly described as "currant jelly" stools, and diarrhea may occur. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees to the chest. This pain progresses to a more severe constant pain. Vomiting may be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are not manifestations of this disorder.
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A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply.
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C. Skeletal muscle weakness D. Hyperactive bowel sounds. Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness, because ventilation depends on strength of the respiratory muscles.
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An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first?
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D. Administering 100% humidified oxygen. Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is assessed, a patent airway is established, and the client is given 100% humidified oxygen. Inserting a Foley catheter, initiating an IV line, and cleansing the burn wound are also components of the plan of care for a burned client, but these are not the immediate actions.
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A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will:
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B. Breastfeed the newborn every 2 to 3 hours. Rationale: Breastfeeding should be initiated within 2 hours of birth and performed every 2 to 3 hours thereafter. Supplementation with water should be avoided because the newborn may take less milk, which is more effective than water in removing bilirubin from the intestines. The infant should not be fed less frequently. It is not necessary to stop breastfeeding and to bottle feed only.
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A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of:
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C. 2 inches. Rationale: When CPR is being performed on an adult, the sternum should be depressed at least 2 inches (5 cm). The other options are incorrect because they are too shallow to be effective or too deep, which can cause damage to internal organs. The rescuer should allow complete recoil of the chest after each compression to allow the heart to fill completely before the next compression.
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A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which of the following interventions does the nurse include in the plan?
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C. Providing a high-calorie, high-protein diet. Rationale: Graves disease is characterized by a hypermetabolic state, and the client benefits most from an environment that is restful both physically and mentally. Therefore the client is encouraged to rest. As compensation for the hypermetabolic state, the client needs a diet that is high in calories and high in protein. Individuals with Graves disease experience heat intolerance and diaphoresis and require a cool environment.
