Nursing Pre-Board Exam for December 2012 NLE

ANSWER: Right-sided paralysis. The single most common factor in skin breakdown is immobility. The right-sided paralysis, in which the client cannot perceive the need to change position and lacks control over the movement of the extremities, is the condition most likely to lead to skin breakdown. It is essential that the nurse plan to change the client's position at least every 2 hours. Nutritional status and urinary incontinence can contribute to skin breakdown, but neither is the most critical factor. Confusion does not directly influence skin breakdown.

ANSWER: Assess urinary output every shift. Morphine can cause urinary retention. The nurse should assess the client for urinary hesitancy or retention, and note the urinary output. It is not necessary to take the apical heart rate after each dose of morphine. Mental status should be assessed after each dose, because morphine can cause such effects as sedation, delirium, and disorientation. Assessing for pedal edema is not a necessity.

ANSWER: 14 gtt/minute The intravenous flow rate is determined by the rate of infusion and the number of drops per milliliter of the fluid being administered: gtt/mL × mL/minute = gtt/minute (the intravenous flow rate). 10 gtt/mL × 500 mL/360 minutes = 13.8 gtt/minute. Therefore, the flow rate should be 14 gtt/minute.

ANSWER: Pulse rate. Clients who continue on a progressive exercise program at home after a myocardial infarction should be taught to monitor their pulse rates. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. Clients should also be taught to decrease exercise if chest pain or dyspnea occurs.

ANSWER: promote circulation to the area. Heat applications cause vasodilation, which promotes circulation to the area, and increase tissue metabolism and leukocyte mobility. Heat applications do not prevent swelling; applications of cold are used to prevent swelling by causing vasoconstriction.

ANSWER: "Tell me more about how you're feeling." By asking the client to tell more about how she is feeling, the nurse is not making any assumptions about what is troubling the client. The nurse should acknowledge the client's feelings and encourage her to discuss them. Saying that this situation must be frustrating involves assumptions by the nurse about why the client is crying and is not a therapeutic response. Asking how long the client has been unable to comb her hair takes the focus off her feelings and inhibits therapeutic communication. Inquiring why the client's husband hasn't helped insinuates that the husband is not helping enough, which is inappropriate, takes the focus off the client's feelings, and inhibits therapeutic communication.

ANSWER: Reschedule the infant's appointment for later in the week. The interpreter must have gotten delayed somewhere. Therefore, the nurse's best action would be to reschedule the child's appointment when the interpreter can be scheduled as well. Because the mother does not speak English, there is no point in having the pediatric nurse practitioner see the infant because history information is needed and most likely would be too difficult to obtain. Asking the mother to stay longer is rude to her. Also, doing so would probably be difficult because of the communication gap. Paging one more time is a desperate measure and inappropriate.

ANSWER: Contact the physician for further orders regarding insulin administration. The nurse should contact the physician and clarify whether the client's usual insulin dose should be given before surgery. Practices vary, and it should not be assumed by the nurse that the usual insulin dose is to be given. It is not the nurse's responsibility to evaluate the client's need for insulin. It is not appropriate for the nurse to defer decision-making on this issue until after surgery.

ANSWER: Oxygenate the client before suctioning. Preoxygenating the client before suctioning helps prevent the development of hypoxia during the procedure. The suction catheter is inserted about 5 to 6 inches into the cannula. A bolus of 3 to 5 mL of sterile normal saline may be inserted into the cannula before suctioning to stimulate coughing and loosen secretions. The nurse uses sterile technique when suctioning a client.

ANSWER: To keep the catheter free from clot obstruction. Continuous irrigation, usually consisting of sterile normal saline, is used after a TURP to keep blood clots from obstructing the catheter and impeding the flow of urine. Antibiotics may be instilled in a bladder with the use of an irrigating solution, but this is not the primary reason for using continuous irrigation in TURP. The irrigating solution may secondarily help prevent bladder distention because it keeps the catheter from becoming obstructed.

ANSWER: Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels "boggy." Vigorous massaging may fatigue the uterus and cause it to become firm and then "boggy" again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client and can cause the uterus to be deviated to one side.

ANSWER: "It is safe to apply a nonperfumed lotion to my skin." Irradiated skin can become dry and irritated, resulting in itching and client discomfort. The client should be instructed to clean the skin gently and apply nonperfumed, nonirritating lotions to help relieve the dryness. Taking an antihistamine does not relieve the skin dryness that is causing the itching. Heat should not be applied to the area, because it can cause further irritation. Medicated ointments, especially corticosteroid ointment, which is controversial, should not be applied to the skin without the order of the radiation therapist.

ANSWER: serotonin. Serotonin, a principal neurotransmitter and appetite suppressant, is produced in the brain from tryptophan. Epinephrine and norepinephrine are made from tyrosine. Phenylalanine is an amino acid found in food.

ANSWER: supplement the diet with pyridoxine (vitamin B6). Isoniazid competes for the available vitamin B6 in the body and leaves the client risk for development of neuropathies related to vitamin deficiency. Supplemental B6 is routinely prescribed to address this issue. Avoiding sun exposure is a preventive measure to lower the risk for skin cancer. Following a low-cholesterol diet lowers the individual's risk for atherosclerotic plaque development. Rest is important in maintaining homeostasis but has no real impact on neuropathies.

ANSWER: Institute droplet precautions The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. Once the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

ANSWER: Wash the buttocks using mild soap. Because the toddler has a severe diaper rash, it may be best to change all that the parents are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air. Baby wipes frequently contain additives and perfumes that may be irritating to the baby's sensitive skin. The diaper needs to be changed more often than every 4 to 6 hours. Otherwise, the moist diaper environment will continue to irritate the already irritated area, causing the rash to worsen. Powder has limited absorbing ability and will most likely irritate the already irritated area. In addition, some powders contain perfumes or are scented and can irritate the skin.

ANSWER: To relax smooth muscles in the bronchioles. Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation.

ANSWER: Participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation, to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

ANSWER: The scrotal sac can be transilluminated. A hydrocele, defined as fluid in the processus vaginalis, is determined when the scrotal sac can be transilluminated. A swelling in the scrotal area that can be reduced indicates an inguinal hernia. Both hydroceles and hernias can enlarge the scrotal sac, and both can be either unilateral or bilateral. A hernia typically is more obvious during crying.

ANSWER: STD A frothy, purulent vaginal discharge in a sexually active female client is typically caused by an STD such as trichomonas. Other diseases, such as chlamydia, may also be present. Both the client and the boyfriend need treatment once the disease is determined. Normal variations in female vaginal discharge should be clear to white, not frothy or purulent. Clients should be instructed to wear cotton underwear and avoid pantyhose and tight-fitting garments such as jeans so that air can circulate.

ANSWER: Blood pressure. Administration of an epidural anesthetic can result in a hypotensive effect on the maternal blood pressure. Therefore, the priority assessment is the mother's blood pressure. Ephedrine or wedging the client to a position to keep pressure off the vena cava, such as on the left side, can be used to elevate the maternal blood pressure should it drop too low. Epidural anesthesia has no effect on the level of consciousness or the client's cognitive function. Although the client's contraction pattern may decrease in frequency after administration of the anesthesia, the priority assessment is the client's blood pressure. Once the blood pressure is maintained, contractions can be assessed.

ANSWER: A 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia. The client who should be assessed first is the multigravid client who has been in labor for 8 hours and whose cervix is 8 cm dilated at 1+ station with contractions every 3 to 4 minutes. A multigravid client typically has a shorter labor than a primigravida, and this client's station is 1+, which means that delivery of the fetus is imminent.

ANSWER: Collect and save the urine voided at 7 am on Tuesday. When finishing a 24-hour urine collection, the final voided urine is saved and added to the collection container. The first urine specimen, voided at 7 am Monday, is discarded. The urine is not sent for a urine culture. It is not necessary to separate each day's collection of urine.

ANSWER: Assist the client with comfort measures and breathing techniques. The client's assessment findings indicate that the client is in the latent phase of the first stage of labor. Therefore, the nurse should plan to assist the client with comfort measures and breathing techniques to relieve the discomfort. The client is able to move around, walk, or ambulate at this phase of labor. If the client chooses to remain in bed, a left side-lying position provides the greatest perfusion. It is too early for the client to have an epidural anesthetic. Epidural anesthesia is usually administered when the cervix is dilated to 5 to 6 cm. The fetal heart rate is normal, so internal fetal monitoring is not warranted at this time.

ANSWER: Position the suppository along the rectal wall. The client should be placed in a side-lying position and encouraged to take a deep breath during the insertion of the suppository. Placing the suppository along the rectal wall promotes absorption of the medication and helps avoid placing it into a stool mass. The nurse should insert the suppository 3 to 4 inches into the rectum of an adult client.

ANSWER: "This medicine will make your mouth feel dry." Atropine sulfate is an anticholinergic drug that decreases mucous secretions in the respiratory tract and dries the mucous membranes of the mouth, nose, pharynx, and bronchi. Atropine does not cause drowsiness or relaxation. Moderate to large doses cause tachycardia and palpitations. Large doses cause excitement and manic behavior. Atropine does not reduce the risk of postoperative infection.

ANSWER: Individualize the pain medication regimen for the client. The nurse should work with the client to individualize the care plan for managing the client's pain. Cancer pain is best managed with a combination of medications, and each client needs to be worked with individually to find the treatment regimen that works best. Cancer pain is frequently undertreated because of fear of addiction. Clients who are experiencing pain need the appropriate level of analgesic and need to be reassured that they will not become addicted. Cancer pain is best treated with regularly scheduled doses of medication. Administering the medication only when the client asks for it will not lead to adequate pain control. As drug tolerance develops, the dosage of the medication can be increased.

ANSWER: Infection. Infection would be of the greatest concern to the nurse. Infection occurs more frequently because of the number of procedures performed on patients that require this therapy and people they come in contact with in the hospital. Infection can be reduced if proper infection control techniques are used and human contact is reduced. Deficiencies and toxicities of nutrients are rare because of the use of standard protocols and orders for TPN formulas. Hyperglycemia can occur with TPN administration; however, all clients receiving TPN have their serum glucose concentration monitored frequently, and the hyperglycemia can easily be managed by adding insulin to the TPN solution. An infection is a much more serious complication.

ANSWER: Acute Pain. Pain is a priority problem for the client with renal calculi. The pain is typically described as excruciating and intermittent, occurring as the stone moves. Analgesics are a major part of therapy. Activity Intolerance is secondary to the excruciating pain. Although the client experiences occasional nausea, there are no data to support a diagnosis of Deficient Fluid Volume or Imbalanced Nutrition.

ANSWER: are in a monogamous relationship. The IUD is suitable for clients who desire long-term contraceptive use and are in a monogamous relationship. Because of the increased risk of spread of infection with an IUD if an STD occurs, the device is not appropriate for women with multiple partners or history of STDs. Previous ectopic pregnancy is also a contraindication for an IUD, because the incidence of ectopic implantation is slightly higher.

ANSWER: Commit to lifelong therapy. The most appropriate long-term goal is for the client with hypertension to commit to lifelong therapy. A significant problem in the long-term management of hypertension is client compliance with the treatment plan. It is essential that the client understand the reasons for modifying lifestyle, taking prescribed medications, and obtaining regular health care. Limiting stress, losing weight, and monitoring blood pressure are important aspects of care for clients with hypertension; however, the treatment plan must be individualized to include aspects of care that are appropriate for each client.

ANSWER: "Tell me more about why you are here and how you feel about that." Encouraging the client to talk about why she is here and about her feelings may reveal more information about both what led her to come to the group and what led to her diagnosis. It also provides the nurse with valuable information needed to develop an appropriate plan of care. The comment that the client sounds angry presumes what the client is feeling and asks her to talk about her husband. The focus here should be on the client, not the husband. Telling the client that she will like coming to group imposes the nurse's view onto the client. The statement stresses that the group will be fun to be a part of instead of on its therapeutic value. Having the client tell the nurse something about the cause of her bulimia ignores the client's original statement. Additionally, this statement requires the client to have insight into the cause of her disease, which may not be possible at this time. Also, it may be too early in the relationship to discuss this disorder.

ANSWER: Assess the parents' current knowledge level before providing information. Before giving information, it is important for the nurse to assess the learner's current level of knowledge. When dealing with parents of an ill child, the nurse considers their emotional strength and the intensity of the situation and deals with them in an accepting, nonthreatening manner. Parents may feel overwhelmed by the events, and they need time to adjust to the situation.

ANSWER: on the abdomen, with legs pulled up under the body. When placed on the abdomen, a neonate pulls the legs up under the body, which puts tension on the perineum. Therefore, after surgery, the neonate should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated.

ANSWER: Increased residual volume, decreased forced expiratory volume, increased total lung capacity, decreased vital capacity. In emphysema, the client's lungs lose elasticity and only partially deflate. Air is trapped in the alveoli. As a result of these pathologic changes, the amount of air remaining in the lungs after forced expiration (residual volume) is increased and the amount of air that can be forcibly exhaled (forced expiratory volume) is decreased. Total lung capacity is increased owing to hyperinflation of the lungs. The maximum amount of air that can be exhaled after maximum inhalation (vital capacity) is decreased.

ANSWER: "I will have the client take 5 to 10 deep breaths every hour." Having the client deep-breathe hourly is the most appropriate action for the assistant to take to help prevent pulmonary complications. The client should be turned at least every 2 hours. Keeping the client's head elevated will not prevent pulmonary complications. Suctioning the client is not an assistant's responsibility, nor does it prevent pulmonary complications.

ANSWER: Dullness. A distended bladder produces a dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drum-like sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

ANSWER: Starting an antihypertensive medication. Introduction of medication is most likely to be added to continue lifestyle modifications. Exercise, smoking cessation, and weight reduction are part of the first steps involved in lifestyle modification.

ANSWER: 10 ml First, convert grams to milligrams: 0.5 g = 500 mg. Then, 1,000 mg / x mL = 500 mg / 5 mL; x = 10 mL.

ANSWERS: Extremities warm to touch.and Decreased muscle pain with activity. The outcomes to achieve for a nursing diagnosis of Ineffective Tissue Perfusion involve evidence of adequate blood flow to the area. The temperature of the involved extremity is an important indicator for a client with peripheral vascular disease. The temperature will indicate the degree to which the blood supply is getting to the extremity. Warmth indicates adequate blood flow. Pain is also an indicator of blood flow. Pain such as muscle pain suggests ischemia and lack of oxygen that results when the oxygen demand becomes greater than the supply. Thus, a decrease in muscle pain with activity would suggest improvement in blood flow to the area. Improved respiratory status and clear lungs are unrelated to ineffective tissue perfusion. Although participation in self-care measures is always helpful, this outcome would be more appropriate for a nursing diagnosis of activity intolerance, fatigue, or self-care deficit.

ANSWER: Perform teaching of health and safety practices to children and their parents. The primary cause of disability and death in children is injury from accidents. Teaching safety measures to children and parents is the best way to decrease injury and accidents.

ANSWER: Interval training on the stationary bicycle. The stationary bicycle would be the most appropriate training modality because it is a non–weight-bearing exercise. Interval training involves rest and exercise. The time that the individual exercises on the stationary bicycle is increased with improved functional capacity, and the rest time is decreased.

ANSWER: Identify at-risk clients on admission to the health care facility. The protocol recommended by the Agency for Healthcare Research and Quality is that all clients who are at risk for pressure ulcer development be identified on admission to health care facilities so that preventive actions can be implemented by the nursing staff. These preventive actions need to be individualized to the client, so automatic placement of all at-risk clients on an every-2-hour turning schedule, a specialty bed, or a high-protein, high-carbohydrate diet is not appropriate.

ANSWER: "The cause is unknown." One of the main techniques used in crisis intervention in the hospital is helping parents begin to gain an intellectual understanding of SIDS. Numerous theories have been proposed, but no specific cause of SIDS has been identified. Evidence suggests that infants with SIDS have chronic hypoxia, possibly from prolonged periodic apnea.

ANSWER: Fetal well-being at this point in the pregnancy. A reactive nonstress test is a positive sign indicating that the fetus is doing well at this point in the pregnancy. For a nonstress test to be a reactive test, at least two accelerations (15 beats or more) of the fetal heart rate lasting at least 15 seconds must occur after movement. If the fetus were compromised, the nonstress test would demonstrate no accelerations in fetal heart rate; a contraction stress test would show fetal heart rate decelerations during simulated labor. Late decelerations are associated with a positive or abnormal contraction stress test. No accelerations in a 20-minute period during a nonstress test may mean that the fetus is sleeping; however, this is interpreted as a nonreactive nonstress test.

ANSWER: Give the ice to the mother and demonstrate what to do. Any injury to the mouth results in copious amounts of blood because the mouth is a highly vascular area. Because the nurse does not know the mother and does not speak Spanish, the most appropriate action is to give the mother the ice and demonstrate what she is to do. The child will be less fearful if the ice is applied by the mother. Calling for an interpreter is appropriate after caring for the immediate need of the child. Grabbing the child away will probably upset the mother more, further adding to the stress experienced by the child.

ANSWER: "I can continue to work at my job at the automobile factory until labor starts." The client needs further instructions when she says, "I can continue to work at my job at the automobile factory until labor starts." The goal is to avoid preterm labor. Because the client is experiencing severe hydramnios, she will most likely be maintained on bed rest to increase uteroplacental circulation and reduce pressure on the cervix. Hydramnios has been associated with increased weight gain caused by the increased amniotic fluid volume. Hydramnios has been associated with gastrointestinal disorders in the fetus, such as tracheoesophageal fistula with stenosis or intestinal obstruction. The client should continue to eat high-fiber foods and should avoid straining, which could lead to ruptured membranes. Stool softeners may also be ordered. The client should report any symptoms of fluid rupture or labor.

ANSWER: Sit down or lie down before taking the nitroglycerin. The nurse should encourage the client to sit down or lie down when he has angina. Nitroglycerin relaxes smooth muscles and dilates vascular beds; therefore, nitroglycerin causes hypotension and the client could fall, causing injury. Nitroglycerin should be stored in a dark container. It should be taken once every 5 minutes for three doses and is placed sublingually, not swallowed.

ANSWER: A 70-year-old woman with episodes of syncope. The 70-year-old woman with syncopal episodes is at greatest risk for falling. The nurse should assess the client's gait and balance and the syncopal episodes. The 22-year-old man with upper body fractures and the 50-year-old man with angina are not fall risks. The 30-year-old woman could be at risk of falling, but she is at less risk than the 70-year-old client with syncope.

ANSWER: Slow movements Psychomotor retardation refers to a general slowdown of motor activity commonly seen in a client with depression. Movements appear lethargic, energy is absent or lacking, and performance of activity is slow and difficult. A flat affect reflects a lack of emotion. An unkempt appearance reflects lack of self-care. Avoiding eye contact reflects low self-esteem or suspiciousness.

ANSWER: Hypokalemia. Hypokalemia is one of the most common causes of digitalis toxicity. It is essential that the nurse carefully monitor the potassium levels of clients taking digitalis preparations to avoid digitalis toxicity. Low serum potassium levels can cause cardiac dysrhythmias.

ANSWER: Visual disturbances. Visual disturbances are a symptom of digitalis toxicity. These disturbances can include double, blurred, or yellow vision. Cardiovascular manifestations of digitalis toxicity include bradycardia, other dysrhythmias, and pulse deficit. Gastrointestinal symptoms include anorexia, nausea, and vomiting.

answer: Many of the passengers may be experiencing feelings of victimization. Major accidents can induce feelings similar to those of victims of other kinds of disasters and crime. Therefore, the nurse calls the crisis nurse to assist the passengers with their feelings of victimization. Passengers may mourn the loss of a vacation, but, with no fatalities, major grief reactions are not expected. Other personnel can take calls from relatives while the crisis nurse helps the passengers. Psychiatric hospitalization is a premature assumption.

ANSWER: Intrauterine infection. Thick, cloudy amniotic fluid is indicative of an intrauterine infection. Typically, the client has a fever, lethargy, and malaise. Greenish-colored amniotic fluid is associated with meconium staining. A strong yellowish color of amniotic fluid is associated with erythroblastosis fetalis, because of the presence of bilirubin and hemolyzed red blood cells. The normal color of amniotic fluid is clear or with a very slight yellow tint later in pregnancy.

ANSWER: diabetic retinopathy Diabetic retinopathy involves background and proliferative retinopathy. Both forms are associated with vascular changes in the basement membrane of the arterioles and capillaries of the choroid and retina. Neuropathy is usually associated with the lower extremities.

ANSWER: Imbalanced Nutrition: Less Than Body Requirements. Nausea and anorexia, and in some situations weight loss, are symptoms experienced by clients with jaundice. Jaundice is associated with high levels of bilirubin in the blood. Causes include hepatitis, yellow fever, and alcoholism. The nursing diagnoses of Pain related to muscle spasms and Ineffective Health Maintenance are not supported by the data. Adult Failure to Thrive is a possible diagnosis; however, more data would be needed to support it.

ANSWER: Conveying empathy and encouraging ventilation. At this time, the client's anger is not out of control, so empathy and talking are appropriate to diffuse the anger. Using "time-out" is appropriate when the client's anger is escalating and the client is no longer able to talk about the anger rationally. Restraints are appropriate only when there is imminent risk of harm to self or others. Future strategies are discussed after the initial incident is resolved.

ANSWER: Diaphoresis. The nurse should assess for signs of impending shock, such as diaphoresis. The client would have hypotension, dysuria, and cool skin.

ANSWER: Drinking from a cup and spilling little of the liquid. Infants at age 7 months are not capable of drinking from a cup without spilling. At age 6 months, infants can partially lift their weight on the hands, enjoy imitating sounds, and are developing separation anxiety.

ANSWER: Vulnerability. During the third trimester, particularly in the seventh month of pregnancy, the client typically exhibits feelings of vulnerability and fear that the baby will be lost. Confirmation that the fetus is "real" occurs during the second trimester. Ambivalence is typically seen and resolved during the first trimester. Body image disturbance commonly occurs during the second trimester because of the profound changes that occur to the body during this time.

ANSWER: Flushing of the face. As the dye is injected, the client may experience a feeling of warmth, flushing of the face, and a salty taste in the mouth. The client should not experience chest pain or cold chills; these would be adverse reactions warranting close monitoring of the client.

ANSWER: The nurse requests an order from the physician to change the dose to an equianalgesic dose of morphine. Current pain guidelines recommend removal of meperidine (Demerol) from formularies and substitution of morphine commonly administered by patient-controlled analgesia. Meperidine can be ordered for severe pain but its use is limited by the high incidence of neurotoxicity (seizures) associated with the accumulation of its metabolite, normeperidine. It is contraindicated for patients with acute pain lasting more than 2 days and in those for whom large daily doses (more than 600 mg) are needed. It would be inappropriate to urge the client to take the acetaminophen and codeine to prevent addiction. Addiction is a psychological condition in which a client is driven to take drugs for reasons that are not therapeutic. The client is in pain and her need for the morphine is therapeutic. Although the client may obtain some relief from relaxation exercises, this alone is not sufficient to provide pain relief to the client.

ANSWER: Provide the client with oral hygiene. The nurse's first action after the removal of a nasogastric tube is to provide the client with oral hygiene. It would then be appropriate to give the client liquids to drink if the client is no longer NPO. There is no association between removal of a nasogastric tube and having the client cough and deep-breathe. Auscultating the client's bowel sounds should be done before removal of the tube, not afterward.

ANSWER: Clean the incision and drain site separately. When cleaning the skin around an incision and drain, the nurse should clean the incision and drain separately to avoid contaminating either wound. This is applying the principle of working from the least contaminated area to the most contaminated area. In this case, both areas are fresh wounds and should be kept separate.

ANSWER: Gastrointestinal hemorrhage. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.

ANSWER: Risk for Aspiration. The client with myasthenia gravis may have impaired ability to swallow. Blood draining down the back of the throat may be aspirated if swallowing is impaired. This client may have an impaired breathing pattern due to weak intercostal muscles; however, the priority is to prevent aspiration. The diagnosis of Risk for Injury is not specific enough in this situation. There are no data to support the diagnosis of Self-Care Deficit.

ANSWER: protamine sulfate. The antidote for heparin is 1% protamine sulfate. Vitamin K is the antidote for warfarin (Coumadin), an oral anticoagulant. Thrombin is a topical anticoagulant.

ANSWER: "Why is your child screaming?" The toddler is screaming for a reason, so it is most therapeutic to ask the mother why the child is screaming. This type of question is nonaccusatory, just seeking information. Asking the mother what happened between her and the child makes the assumption that something did happen and limits the amount of information to be gained from the question. Asking whether something caused the child to be upset makes an assumption that something happened and limits the answer to a yes or no response, cutting off communication. Asking whether the mother has tried to calm the child is accusatory and also limits the response to yes or no, thus cutting off communication.

ANSWER: Sore throat and malaise. The common presenting symptoms vary greatly but most frequently include fever, malaise, sore throat, and lymphadenopathy. Skin rash, cold symptoms, abdominal pain, and weight loss are less common symptoms.

ANSWER: Petrolatum gauze dressing. Immediately after chest tube removal, a petrolatum gauze is placed over the wound and covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air movement in either direction. Bandages or straps are not applied directly over wounds. Mesh gauze would allow air movement

ANSWER: Stoppage of body movements when sound is introduced. In response to hearing a noise, normally hearing infants blink or startle and stop body movements. Shy and withdrawn behaviors are characteristic of older children with hearing impairment. Squealing occurs in 90% of infants by 4 months of age. The majority of infants are able to say "da-da" by 9 months of age.

ANSWER: Hypoalbuminemia. Hypoalbuminemia occurs in cirrhosis because the liver cannot synthesize albumin. This causes a decrease in colloidal osmotic pressure, resulting in ascites. Hyperkalemia is not an expected electrolyte imbalance of cirrhosis. The AST and ALT values are increased in liver disease.

ANSWER: Look for meaning in what the client says. The nurse's response fails to identify the meaning in what the client has said. The nurse needs to explore the client's statement about hating God for that flood because the meaning of the client's statement is unclear. Also, clichés such as, "Don't feel that way," are not helpful because they ignore the client's feelings and his interpretation of the situation in which he finds himself. Explaining to the client why he may think as he does (ie, offering a rationale) indirectly argues the delusion and thus is inappropriate. The nurse's response fails to identify the meaning in what the client has said and does not add strength to the support systems. Retaining a delusion does not indicate that a client is solving his problems.

ANSWER: Administering the DTaP and IPV immunizations. At this time, the infant can be given the DTaP and IPV, but not live vaccines. The fact that the child's sibling is immunosuppressed because of chemotherapy would alert the nurse not to give a live vaccine. The fact that the child has a cold is not grounds for delaying the immunizations. However, if the child had a fever, the immunizations would be delayed.

ANSWER: Fluid imbalances. Clients receiving TPN are at risk for a number of complications, including fluid imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary hypertension, and postural hypotension are not complications of TPN.

ANSWER: Cook all meats such as beef and pork thoroughly. Toxoplasmosis is a protozoal infection caused by Toxoplasma gondii, which is transmitted through ingestion of raw or undercooked meat, through contact with infected cat feces, or across the placental barrier from the mother to the fetus. The mother should be instructed to cook all meats thoroughly, avoid touching the mucous membranes when handling raw meat, thoroughly clean all kitchen surfaces that have come in contact with raw meat, avoid uncooked eggs, and avoid contact with cat litter boxes and cat feces. The disease is not spread by contact with an infected person. Although prophylactic penicillin may be used for pregnant clients who test positive for group B streptococcus, penicillin is not used to treat toxoplasmosis. Toxoplasmosis may be treated with a combination of pyrimethamine (Daraprim) and sulfadiazine, accompanied by folic acid to reduce the toxicity of the other two drugs. However, controversy exists about whether to treat the mother. There is no vaccine for toxoplasmosis. Although a vaccine exists for rubella, this would be given not during pregnancy but within 72 hours postpartum if the client is not immune.

ANSWER: Risk for Injury (airway obstruction) related to epiglottal edema. The child's signs and symptoms in conjunction with the acute onset suggest possible croup or epiglottitis. The priority diagnosis at this time would be Risk for Injury. The airway may become completely occluded by the epiglottis at any time. Although the child is probably experiencing fear and anxiety, and impaired gas exchange may occur with continued respiratory distress, the immediate priority is a patent airway. No evidence is provided to support aspiration and ineffective airway clearance.

ANSWERS: Rebound hypoglycemia. When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse should assess the client for symptoms of hypoglycemia. Essential fatty acid deficiency is very unlikely to occur because some of these fatty acids are stored. Preventing dehydration or malnutrition is not the reason for tapering the infusion rate; the client's hydration and nutritional status and ability to maintain adequate intake must be established before the TPN is discontinued.

ANSWER: Empty the urinary appliance when one-third full. The urinary appliance should be emptied before the pouch is one-third full in order to prevent urinary reflux. The appliance should be attached to a leg bag at night to allow for adequate drainage. It is not appropriate to administer prophylactic antibiotics when incorporating positive self-care activities into the client's routine can prevent most urinary tract infections. The urinary appliance is not changed daily. If no leakage occurs and the client's skin remains free of irritation, the appliance can be left in place for a week or more.

ANSWER: Hemoglobin, hematocrit, and platelet count The baseline laboratory data that are established before a client is started on t-PA or alteplase recombinant (Activase) include hematocrit, hemoglobin, and platelet count.

ANSWER: "I can't wait to take a tub bath when I get home." The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can implement the prescribed exercise program at the time of discharge home. The client should take care not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during the recovery from surgery.

Answer: Using incentive spirometry every 2 hours while awake. A major goal of postoperative care for the client who has had an incisional cholecystectomy is the prevention of respiratory complications. Because of the location of the incision, the client has a difficult time breathing deeply. Use of incentive spirometry promotes chest expansion and decreases atelectasis. Performing leg exercises each shift is not frequent enough; they should be performed hourly. Maintaining a weight reduction diet may be appropriate for the client, but it is not the highest priority in the immediate postoperative phase. Promoting wound healing is important, but respiratory complications are most common after a cholecystectomy.

ANSWER: She weighs 6 pounds less than she did 2 days ago. The primary reason to give a diuretic to a client with heart failure is to promote sodium and water excretion through the kidneys. As a result, the excessive body water that tends to accumulate in a client with heart failure is eliminated, which causes the client to lose weight. Monitoring the client's weight daily helps evaluate the effectiveness of diuretic therapy. The client should be advised to weigh herself daily. An increased appetite or decreased thirst does not establish the effectiveness of the diuretic therapy, nor does having clearer urine after starting the torsemide.

ANSWER: an increase in the hypoglycemic effects of insulin. There is a direct interaction between the effects of insulin and those of -blockers. The nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a -blocker is added to the client's medication regimen. The client's blood sugar should be monitored. Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could occur when a -blocker is added, the direct result is an increase in the hypoglycemic effect of insulin.

ANSWER: Urinary retention. Propantheline bromide is an anticholinergic drug. Common side effects include urinary retention and constipation; flushed, dry skin; and dry mouth, nose, and throat. Postural hypotension may also occur. Diarrhea and diaphoresis are side effects of cholinergic drugs

ANSWER: Dependent edema. Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.

ANSWER: "Your child needs all of the medicine so that the infection clears." Frequently, when a child appears better, the parents stop the medication. Unfortunately, the infection remains. Therefore, the nurse needs to explain that all of the medication is needed to clear up the infection. Explaining why the medicine should be continued is more helpful to parents than saying it needs to be given. Asking how the mother knows that her child's ears are better is blaming and would diminish the mother's self-esteem. Telling the mother that stopping the medication is not what is best for the child implies blame and is condescending.

ANSWER: 40% Oxygen concentrations greater than 40% have been found to cause oxygen toxicity in adults.

ANSWER: Distend the veins. Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial circulation.

ANSWER: Estrogen. Increasing estrogen levels during puberty are responsible for breast development. Prolactin is a hormone necessary for milk production during pregnancy and lactation. Progesterone maintains a pregnancy after conception. Testosterone is responsible for male sexual development during puberty.

ANSWER: Sitting forward with arms supported on bedside table. In preparation for a thoracentesis the client should be asked to sit forward and place arms on the bedside table for support. This position provides access to the chest wall and intercostal spaces for insertion of the needle. The supine, Sims', or prone position would not provide adequate access to the chest wall or separate the intercostal spaces sufficiently for needle insertion.

ANSWER: Low, requiring further medical intervention. Normal cardiac output is 4 to 8 L/minute. The value does vary with body size, but 2.2 L/minute is very low and can be life-threatening. For the client with a cardiac output of 2.2 L/minute, the nurse would anticipate that the physician would adjust the medication regimen. The client may experience symptoms of dyspnea and fatigue, requiring nursing intervention.

ANSWER: Protamine sulfate. Protamine sulfate is a heparin antagonist. It is administered intravenously very slowly (over at least 10 minutes). Warfarin sodium (Coumadin) and acetylsalicylic acid (ASA) have anticoagulant properties and would be contraindicated. Atropine sulfate is an anticholinergic drug and would not be effective in treating a heparin overdose.

ANSWER: 0.5 0.125 mg / x tablets = 0.25 mg / 1 tablet; x = 0.5 tablets.

ANSWER: Playing a card game with a boy the same age. Teenagers usually enjoy activities with peers in preference to socializing with their parents or siblings. Peer relationships help the adolescent develop self-identity.

ANSWER: Ambivalence about the pregnancy. Ambivalence is a common reaction, even when the pregnancy was planned. Manifested by conflicting feelings about the pregnancy, it usually resolves during the first trimester. There is no indication of disappointment. A statement such as, "I really don't want to be pregnant," would indicate disappointment. There is no indication that the client desires an abortion, although this is an option for the client. There is no reason to suspect that bonding will be a problem after delivery, unless the client shows no signs of wanting to care for the infant after delivery.

ANSWER: Personal values. According to Erikson, a child of 13 years is normally seeking to meet the need to develop personal identity. Personal values are a component of this identity. Developing a conscience is a component of achieving initiative during the preschool years. Developing a sense of competence is a component of achieving industry of the school-aged years. Developing a lifetime vocation is a component of achieving generativity in adulthood.

ANSWER: The scar will be small and The teen will be back in school in a week. Teens are very concerned about their body image and knowing about the size of the scar is important to them. Typically, teens return to school in 1 week. While hospitalized, friends can visit during visiting hours. Clients are usually hospitalized for an uncomplicated appendectomy for about 24 hours. Antibiotics are not routinely given to prevent an infection. The dressing is removed within a few days.

ANSWER: Prone. To help prevent flexion deformities, a client with rheumatoid arthritis should lie in a prone position in bed for about one-half hour several times a day. This positioning helps keep the hips and knees in an extended position and prevents joint flexion. Low Fowler's, modified Trendelenburg, and side-lying positions do not prevent hip flexion.

ANSWER: life-threatening ventricular dysrhythmias. Cardiomyopathy means that the myocardium is weak and irritable. Amiodarone is an antiarrhythmic and acts directly on the cardiac cell membrane. In this situation, amiodarone would be used to increase the ventricular fibrillation threshold. Amiodarone is contraindicated in sinus node dysfunction, heart block, and severe bradycardia.