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NEW QUESTION 430
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
- A. Allow the infant to breast-feed at the next feeding time to empty the breasts
- B. Take a warm shower and express milk from both breasts until empty
- C. Apply ice packs to the breasts and wear a supportive, well-fitting bra
- D. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
Answer: C
Explanation:
Section: Questions Set F
Explanation
Explanation:
(A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 1κΆ€2-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
NEW QUESTION 431
Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to:
- A. Administer the as-needed dose of phenytoin (Dilantin)
- B. Check the client's potassium level
- C. Assist the client to do range of motion exercises
- D. Report the findings to the physician
Answer: D
Explanation:
(A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. (B) Range of motion exercises are not appropriate topresenting symptoms. (C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. (D) Phenytoin is indicated for seizure activity mainly of neurological origin.
NEW QUESTION 432
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:
- A. "Tell me more about what you couldn't take anymore."
- B. "I'm sure you probably didn't mean to kill yourself."
- C. "You shouldn't do things like that, just tell someone you feel bad."
- D. "How long have you been in the hospital."
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization.
(C) Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
NEW QUESTION 433
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
- A. Responsive to touch, wants to be held
- B. Maintains eye-to-eye contact
- C. Finicky eater, easily pacified, cuddly
- D. Uncomforted by touch, refuses bottle
Answer: D
Explanation:
(A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye contact. (D) Maternal deprivation behaviors include displeasure with touch and physical contact.
NEW QUESTION 434
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:
- A. Elevate right lower extremity with pillows propped under the knee
- B. Assess for edema and heat of the right leg
- C. Instruct him to rub the cramp out of his leg
- D. Assess for pain with plantiflexion
Answer: B
Explanation:
(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.
NEW QUESTION 435
Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse's response is based on the knowledge that chronic osteomyelitis:
- A. Is caused by poor physical conditions or poor nutrition
- B. May develop from sinuses in the involved bone that retain infectious material
- C. Often results from unhygienic conditions or an unclean environment
- D. Is directly related to sluggish circulation in the affected limb
Answer: B
Explanation:
(A) Poor nutrition and/or poor physical conditions are factors that predispose to the development of osteomyelitis but do not cause it. (B) An unclean or unhygienic environment may predispose to the development of chronic osteomyelitis, but it does not cause an exacerbation of the previous infection. (C) Sluggish circulation through the medullary cavity during acute osteomyelitis may delay healing, but it does not cause the disease to become chronic. (D) Areas of sequestrum may be surrounded by dense bone, become honeycombed with sinuses, and retain infectious organisms for a long time.
NEW QUESTION 436
A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse's knowledge of the central nervous system, the nurse knows that benign tumors:
- A. Do not warrant concern because they do not become malignant tumors
- B. Can be just as dangerous as malignant tumors
- C. Grow more rapidly than malignant tumors
- D. Can be removed surgically
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Both a benign and a malignant tumor can displace or destroy nearby structures or increase intracranial pressure. (B) Benign or malignant brain tumors grow at different rates depending on the type of tumor. (C) Some benign tumors do become malignant tumors. (D) Whether or not a tumor is operable depends on its location and the amount of damage its removal will cause.
NEW QUESTION 437
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
- A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
- B. Advise the client to discontinue the drug at the first sign of dizziness.
- C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
- D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
Answer: A
Explanation:
(A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.
NEW QUESTION 438
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. Regular
- B. NPH
- C. Human or pork
- D. Long acting
Answer: A
Explanation:
(A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV.
NEW QUESTION 439
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. A left hemothorax
- B. A right hemothorax
- C. Intubation of the right mainstem bronchus
- D. An inadequate mechanical ventilator
Answer: C
Explanation:
(A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.
NEW QUESTION 440
A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral reflux. Which statement by her mother indicates a need for further teaching?
- A. "I have taught her to wipe from front to back after urinating."
- B. "She tries to empty her bladder completely after she urinates, like I told her."
- C. "I make sure she drinks plenty of fluids every day."
- D. "She enjoys wearing nylon panties, but I make her change them everyday."
Answer: D
Explanation:
Section: Questions Set E
Explanation:
(A) Wiping from front to back is wiping from an area of lesser contamination (urethra) to an area of greater contamination (rectum). (B) Generous fluid intake reduces the concentration of urine. (C) Cotton is a natural, absorbent fabric. Nylon often predisposes the client to urinary tract infections. Dark, warm, moist areas are excellent media for bacterial growth. (D) With vesicoureteral reflux, urine refluxes into the ureter(s) during voiding and then returns to the bladder (residual), which becomes a source for future infection.
NEW QUESTION 441
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
- A. Use artificial tears
- B. Limit activities which require focusing (close vision)
- C. Wear a patch over one eye
- D. Take more frequent naps
Answer: C
Explanation:
(A)
Limiting activities requiring close vision will not alleviate the discomfort of double vision.
(B)
Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
NEW QUESTION 442
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
- A. The nurse should use universal precautions when obtaining blood samples.
- B. Total bed rest should be maintained until the client is asymptomatic.
- C. The client should be instructed to maintain a low semi-Fowler position when eating meals.
- D. The nurse should administer an alcohol backrub at bedtime.
Answer: A
Explanation:
(A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C.
A high Fowler position may decrease the tendency to vomit. (D) The buildup of bilirubin in the client's skin may cause pruritus. Alcohol is a drying agent.
NEW QUESTION 443
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
- A. Seizure
- B. Headache
- C. Ataxia
- D. Bulging fontanelles
Answer: B
Explanation:
(A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.
NEW QUESTION 444
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
- A. Potassium level of 6.3 mEq/L
- B. Chloride level of 99 mEq/L
- C. Sodium level of 136 mEq/L
- D. Potassium level of 3.1 mEq/L
Answer: A
Explanation:
(A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetic ketoacidosis. (D) When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L.
NEW QUESTION 445
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse's first intervention should be to:
- A. Notify the attending physician
- B. Prepare for the delivery because the client is probably in transition
- C. Check FHT
- D. Turn off the IV oxytocin
Answer: D
Explanation:
Explanation
(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
NEW QUESTION 446
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
- A. Falling asleep
- B. Rolling from his back to his tummy
- C. Sucking his thumb
- D. Crying
Answer: D
Explanation:
(A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.
NEW QUESTION 447
A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).
The nurse would need to provide more client education based on which client statement?
- A. "Condoms reduce the transmission of HIV."
- B. "HIV is a virus that is easily transmitted by casual contact."
- C. "HIV can be transmitted to an unborn infant."
- D. "HIV is a virus transmitted by sexual contact."
Answer: B
Explanation:
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective barrier to prevent HIV transmission. (C) HIV is not easily transmitted by casual contact. (D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
NEW QUESTION 448
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
- A. Assists with ambulation
- B. Increases venous return and cardiac output by normalizing fluid status
- C. Decreases hypertrophic scar formation
- D. Covers burn scars and decreases the psychological impact during recovery
Answer: C
Explanation:
Explanation
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6-12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
NEW QUESTION 449
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. A tension pneumothorax
- B. Pneumonia
- C. Pulmonary embolus
- D. An asthma attack
Answer: D
Explanation:
Section: Questions Set D
Explanation:
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings:
agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation.
Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus.
(D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
NEW QUESTION 450
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
- A. Thirst, weight loss, and polyuria
- B. Pain in his legs when he walks
- C. Weight gain, edema in his lower extremities, and shortness of breath
- D. Drowsiness and lethargy after his activities
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure.
The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.
NEW QUESTION 451
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