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NEW QUESTION 463
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Maintaining an adequate level of hydration
- B. O2 therapy
- C. Preventing infection
- D. Providing pain relief
Answer: A
Explanation:
(A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
NEW QUESTION 464
A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:
- A. Conversion
- B. Hallucination
- C. Delusion
- D. Illusion
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
NEW QUESTION 465
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
- A. Gastritis
- B. Evisceration
- C. Peritonitis
- D. Pulmonary embolism
Answer: C
Explanation:
Explanation
(A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
NEW QUESTION 466
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
- A. Holding the head to one side and pointing the chin toward the other side
- B. Holding the head erect and in the midline when in a vertical position
- C. Hyperextension of the neck with evidence of pain on flexion
- D. Significant head lag when raised to a sitting position
Answer: D
Explanation:
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
NEW QUESTION 467
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
- A. Tachycardia
- B. Irregular pulse
- C. Thready pulse
- D. Bradycardia
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) A thready pulse is indicative of hypotension and excessive blood loss and is often rapid. (B) Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman. (C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth. (D) Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
NEW QUESTION 468
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the overall time of the labor process
- B. Prolongs the client's third stage of labor
- C. Prolongs the client's first stage of labor
- D. Decreases the time of the client's first stage of labor
Answer: C
Explanation:
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
NEW QUESTION 469
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?
- A. Hypomagnesemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hypocalcemia
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A deficit in sodium concentration results in muscular weakness and lethargy. (B) Muscle fatigue and hypotonia are caused by hypercalcemia. (C) Muscle weakness and fatigue are classic signs of hypokalemia. (D) Hypermagnesemia can cause muscle weakness, paralysis, and coma.
NEW QUESTION 470
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The nurse has placed the suction catheter in the esophagus.
- B. This is a normal finding.
- C. The client aspirated tube feeding.
- D. The feeding is infusing into the trachea.
Answer: C
Explanation:
(A)
Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus.
(C)
Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.
NEW QUESTION 471
A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?
- A. Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals
- B. A bland, moist, soft diet
- C. Staying with the client and providing distraction during meals
- D. Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals
Answer: B
Explanation:
(A) Local anesthetics do temporarily relieve the pain but leave an unpleasant taste and numb feeling that are not conductive to eating. (B) Such a diet is less irritating to the damaged mucosa and is easier for the child to tolerate. (C) This intervention is helpful if the child has only anorexia. It does not work if the type and texture of the food increase oral discomfort. (D) Lemon glycerin swabs and milk of magnesia dry the oral mucosa and should be avoided.
NEW QUESTION 472
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?
- A. Hypertension is a primary side effect.
- B. Bromocriptine stimulates the production of prolactin.
- C. Bromocriptine is generally taken for 5 days.
- D. Her blood pressure must be stable before starting bromocriptine.
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Bromocriptine inhibits the secretion of prolactin. (B) Hypotension is a side effect of this drug; hypertension is not. (C) Bromocriptine is generally taken for 14 days. (D) The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client's blood pressure is stable, because it can cause hypotension and syncope.
NEW QUESTION 473
A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.5 mEq/L
- B. 1.0 mEq/L
- C. 2.2 mEq/L
- D. 0.03 mEq/L
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This value is a low blood level. (B) This value is a toxic blood level. (C) This value is a low blood level.
(D) This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
NEW QUESTION 474
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply ice packs to both legs.
- B. Immerse both legs in cool water.
- C. Begin débridement by removing all charred clothing from wound.
- D. Apply Silvadene cream (silver sulfadiazine).
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage.
Débridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
NEW QUESTION 475
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
- A. "Do you eat red meat?"
- B. "Have your stools been normal?"
- C. "Do you take aspirin on a regular basis?"
- D. "Do you drink alcohol on a regular basis?"
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character.
NEW QUESTION 476
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
- A. After the interview, call child protective services.
- B. Ask the parents what they could have done differently to prevent this from happening to the child.
- C. Be direct, honest, and attentive.
- D. Approach them in the emergency room as soon as you suspect abuse to "clear the air" right away.
Answer: C
Explanation:
Section: Questions Set E
Explanation/Reference:
Explanation:
(A) The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. (B) The nurse should approach the parents in private, away from the child. (C) Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's "accident." At this point, the parents may get defensive and stop communicating. (D) Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.
NEW QUESTION 477
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. The client's maintaining a semi-Fowler position
- B. IV fluids of 2.5-3 liters in 24 hours
- C. Prolonged bed rest
- D. Cerebral hypoxia
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
NEW QUESTION 478
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
- A. Bran flakes with fresh peaches
- B. Lasagna with garlic bread
- C. Cauliflower and lettuce salad
- D. Broiled fish with rice
Answer: D
Explanation:
(A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein.
NEW QUESTION 479
The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
- A. Interferes with iron absorption because the iron precipitates as an insoluble substance
- B. Will cause more premenstrual cramping
- C. Will bind calcium and therefore interfere with its metabolism
- D. Causes competition at iron-receptor sites between iron and vitamin B1
Answer: A
Explanation:
Explanation
(A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk.
Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients.
NEW QUESTION 480
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Protect the outer surface of the pad from contamination
- B. Wear gloves for the procedure
- C. Place and adjust the pad from back to front
- D. Cleanse and wipe the perineum from front to back
Answer: D
Explanation:
Explanation
(A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. (B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis.
NEW QUESTION 481
A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
- A. Normal blood gases
- B. Uncompensated respiratory acidosis
- C. Compensated respiratory acidosis
- D. Uncompensated metabolic acidosis
Answer: B
Explanation:
(A) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client's primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (B) Normal ranges for arterial blood gases for adults and children are as follows: pH 7.35-7.45, PO280-100 mm Hg, PCO235-45 mm Hg, HCO321-28 mEq/L. (C) In uncompensated metabolic acidosis the pH level is decreased, the PCO2level is normal, and the HCO3level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys. The lungs are unable to clear the increased acid. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. In a person with long-standing COPD, the HCO3level will rise gradually over time to compensate for the gradually increasing PCO2, and the person's pH level will be normal. When a person with COPD becomes acutely ill, the kidneys do not have time to increase the reabsorption of HCO3, so the person's pH level will reflect acidosis even though the HCO3is elevated.
NEW QUESTION 482
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