Skin breakdown occurs on a client's hand at the site of an intravenous catheter that
had medication infusing. The nurse determines that which adverse effect occurred?
Rationale:
Extravasation refers to the tissue injury that occurs from leakage of medication into
surrounding skin and subcutaneous tissue; it can also cause tissue necrosis.
Phlebitis is an inflammation of the vein that can occur from mechanical or chemical
(medication) trauma or from a local infection. Phlebitis can cause the development
of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of
the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but
the injury is not to the extent that occurs with extravasation.
Metformin is prescribed for a client with type 2 diabetes mellitus. Which would the
nurse tell the client is a common side effect of the medication?
Rationale:
The most common side effect of metformin is GI disturbances, including decreased
appetite, nausea, and diarrhea. These generally subside over time. This medication
does not cause weight gain; in fact, clients lose an average of 7 to 8 pounds
because the medication causes decreased appetite. Hypoglycemia may be an
adverse effect.
A client becomes increasingly more anxious and hyperventilates during the
transition phase of labor. The nurse recognizes that the client needs what?
Rationale:
When the woman enters this phase of labor, her anxiety level tends to increase as
she senses the fairly constant intensification of contractions and pain. The client
may need help regaining focus and her breathing pattern. General anesthesia is not
needed in this situation. The nurse encourages the woman to refrain from pushing
until the cervix is completely dilated and the urge to push is present. The client may
be terrified of being left alone during this phase of labor.
An adolescent with diabetes mellitus is attending gym class and suddenly becomes
flushed and complains of dizziness and a headache. The gym teacher quickly takes
the adolescent to the school nurse's office. The nurse obtains a blood glucose level,
and the results indicate a level of 65 mg/dL. Which initial nursing intervention is
appropriate?
Rationale:
A blood glucose level below 70 mg/dL indicates hypoglycemia. The child is
participating in an activity that requires more energy than that of the normal
routine at school. Insulin and food requirements change with situations that require
more energy. When signs of hypoglycemia occur, the child needs an immediate
source of glucose
The nurse is reinforcing medication instructions to a client with a diagnosis
of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which
instruction would the nurse most appropriately provide the client in
regard to taking this medication?
Rationale:
Saquinavir is an antiviral medication. It is administered within 2 hours after a
full meal. If the medication is taken without food in the stomach, it may result in
no antiviral activity.
,The nurse is caring for a client with a nasogastric tube in place for gastric
decompression. The gastroenterologist prescribes to have the tube irrigated once
every 8 hours. Select the correct interventions the nurse would utilize in
performing this procedure. Select all that apply.
Rationale:
A nasogastric tube is usually a Salem sump tube that is inserted through the naris
with the end of the tube in the stomach. The tube is connected to low suction to
remove gastric secretions and rest the bowel. Irrigation is done to maintain
patency of the tube. Normal saline is used to limit loss of electrolytes. The usual
amount is 30 mL injected through the tube, not the air vent, and then aspirated
back into the syringe. The nurse should follow aseptic technique wearing clean
gloves, not sterile technique. The client's serum electrolyte results do not need to
be monitored since normal saline is the correct solution for irrigation.
The nurse is performing a postpartum fundal assessment on a client 6 hours after
delivery. The nurse finds the fundus above the umbilicus and displaced to the right.
Which intervention would the nurse do first?
Rationale:
A full bladder causes the uterus to be displaced above the umbilicus and well to
one side of the abdominal midline. After voiding, if the fundus is boggy, it can be
massaged, but this is not the first action. The woman should be assisted to the
bathroom to void and then the fundus should be reassessed. Turning the client to
her left side will not bring the fundus to midline. This is not a normal finding; the
fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6
hours after delivery.
The nurse is performing a postpartum fundal assessment on a client 6 hours after
delivery. The nurse finds the fundus above the umbilicus and displaced to the right.
Which intervention would the nurse do first?
Rationale:
A full bladder causes the uterus to be displaced above the umbilicus and well to
one side of the abdominal midline. After voiding, if the fundus is boggy, it can be
massaged, but this is not the first action. The woman should be assisted to the
bathroom to void and then the fundus should be reassessed. Turning the client to
her left side will not bring the fundus to midline. This is not a normal finding; the
fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6
hours after delivery.
A licensed practical nurse is explaining the appropriate methods for measuring
an accurate temperature to an assistive personnel (AP). Which method, if
noted by the AP as being an appropriate method, indicates the need for
further teaching?
Rationale:
An oral temperature should be avoided if the client has nasal congestion. One of
the other methods of measuring the temperature should be used according to the
equipment available. Taking a rectal temperature for a client who has undergone
nasal surgery is appropriate. Other less invasive measures should be used if
available; if they are not available, a rectal temperature is acceptable. Taking an
axillary temperature on a client who just consumed coffee is also acceptable;
however, the axillary method of measurement is the least reliable, and other
, methods should be used if available. If temporal equipment is available and the
client is diaphoretic, it is acceptable to measure the temperature on the neck
behind the ear, avoiding the forehead.
A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about
the disorder. The nurse plans to base the response on which information?
Rationale:
Hirschsprung's disease, also known as "congenital aganglionosis" or "megacolon,"
is the result of an absence of ganglion cells in the rectum and to varying degrees
upward in the colon
The nurse is reinforcing instructions about home safety measures regarding
medications and toxic substances to a parent. Which parent statements indicate
a need for further teaching? Select all that apply.
Rationale:
Home safety measures are very important to prevent unnecessary childhood
poisoning or death. Medicine should never be referred to as "candy." This could
tempt a child to try to eat it when the parents are not in the immediate vicinity.
Each medication should be correctly labeled and kept in a separate bottle to avoid
problems with identification of the medication actually taken. Toxic substances
should be labeled with green poison stickers and placed in a locked area out of
reach of children. The poison control center telephone number should be visible
near all telephones. Medications should be stored in childproof containers.
A client who experienced ventricular fibrillation has just been defibrillated.
Following the defibrillation, which action would the nurse take
immediately?
Rationale:
Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if
a normal rhythm has been restored, the heart pump needs to be reprimed to
provide improved cerebral blood flow to improve neurological outcome.
A mother of a 3-year-old is concerned because the child is still insisting on a bottle
at nap time and at bedtime. The nurse would make which suggestion to the
mother?
Rationale:
A toddler should not be allowed to fall asleep with a bottle because of the risk of
dental caries. If the bottle is allowed in bed, it should contain only water.
A client with a diagnosis of a recurrent major depression, exhibiting psychotic
features, is admitted to the mental health unit. In an attempt to create a safe
environment for the client, the nurse designs a plan of care that deals specifically
with which aspect of the client's disorder?
Rationale:
Altered thought process requires the nurse to create a plan of care that includes a
safe environment. Altered thought processes can include the presence of
hallucinations and delusions. A recurrent major depression with psychotic features
alerts the nurse that care must be planned to address both the major depression
and the psychosis. Psychosis is defined as a
had medication infusing. The nurse determines that which adverse effect occurred?
Rationale:
Extravasation refers to the tissue injury that occurs from leakage of medication into
surrounding skin and subcutaneous tissue; it can also cause tissue necrosis.
Phlebitis is an inflammation of the vein that can occur from mechanical or chemical
(medication) trauma or from a local infection. Phlebitis can cause the development
of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of
the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but
the injury is not to the extent that occurs with extravasation.
Metformin is prescribed for a client with type 2 diabetes mellitus. Which would the
nurse tell the client is a common side effect of the medication?
Rationale:
The most common side effect of metformin is GI disturbances, including decreased
appetite, nausea, and diarrhea. These generally subside over time. This medication
does not cause weight gain; in fact, clients lose an average of 7 to 8 pounds
because the medication causes decreased appetite. Hypoglycemia may be an
adverse effect.
A client becomes increasingly more anxious and hyperventilates during the
transition phase of labor. The nurse recognizes that the client needs what?
Rationale:
When the woman enters this phase of labor, her anxiety level tends to increase as
she senses the fairly constant intensification of contractions and pain. The client
may need help regaining focus and her breathing pattern. General anesthesia is not
needed in this situation. The nurse encourages the woman to refrain from pushing
until the cervix is completely dilated and the urge to push is present. The client may
be terrified of being left alone during this phase of labor.
An adolescent with diabetes mellitus is attending gym class and suddenly becomes
flushed and complains of dizziness and a headache. The gym teacher quickly takes
the adolescent to the school nurse's office. The nurse obtains a blood glucose level,
and the results indicate a level of 65 mg/dL. Which initial nursing intervention is
appropriate?
Rationale:
A blood glucose level below 70 mg/dL indicates hypoglycemia. The child is
participating in an activity that requires more energy than that of the normal
routine at school. Insulin and food requirements change with situations that require
more energy. When signs of hypoglycemia occur, the child needs an immediate
source of glucose
The nurse is reinforcing medication instructions to a client with a diagnosis
of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which
instruction would the nurse most appropriately provide the client in
regard to taking this medication?
Rationale:
Saquinavir is an antiviral medication. It is administered within 2 hours after a
full meal. If the medication is taken without food in the stomach, it may result in
no antiviral activity.
,The nurse is caring for a client with a nasogastric tube in place for gastric
decompression. The gastroenterologist prescribes to have the tube irrigated once
every 8 hours. Select the correct interventions the nurse would utilize in
performing this procedure. Select all that apply.
Rationale:
A nasogastric tube is usually a Salem sump tube that is inserted through the naris
with the end of the tube in the stomach. The tube is connected to low suction to
remove gastric secretions and rest the bowel. Irrigation is done to maintain
patency of the tube. Normal saline is used to limit loss of electrolytes. The usual
amount is 30 mL injected through the tube, not the air vent, and then aspirated
back into the syringe. The nurse should follow aseptic technique wearing clean
gloves, not sterile technique. The client's serum electrolyte results do not need to
be monitored since normal saline is the correct solution for irrigation.
The nurse is performing a postpartum fundal assessment on a client 6 hours after
delivery. The nurse finds the fundus above the umbilicus and displaced to the right.
Which intervention would the nurse do first?
Rationale:
A full bladder causes the uterus to be displaced above the umbilicus and well to
one side of the abdominal midline. After voiding, if the fundus is boggy, it can be
massaged, but this is not the first action. The woman should be assisted to the
bathroom to void and then the fundus should be reassessed. Turning the client to
her left side will not bring the fundus to midline. This is not a normal finding; the
fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6
hours after delivery.
The nurse is performing a postpartum fundal assessment on a client 6 hours after
delivery. The nurse finds the fundus above the umbilicus and displaced to the right.
Which intervention would the nurse do first?
Rationale:
A full bladder causes the uterus to be displaced above the umbilicus and well to
one side of the abdominal midline. After voiding, if the fundus is boggy, it can be
massaged, but this is not the first action. The woman should be assisted to the
bathroom to void and then the fundus should be reassessed. Turning the client to
her left side will not bring the fundus to midline. This is not a normal finding; the
fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6
hours after delivery.
A licensed practical nurse is explaining the appropriate methods for measuring
an accurate temperature to an assistive personnel (AP). Which method, if
noted by the AP as being an appropriate method, indicates the need for
further teaching?
Rationale:
An oral temperature should be avoided if the client has nasal congestion. One of
the other methods of measuring the temperature should be used according to the
equipment available. Taking a rectal temperature for a client who has undergone
nasal surgery is appropriate. Other less invasive measures should be used if
available; if they are not available, a rectal temperature is acceptable. Taking an
axillary temperature on a client who just consumed coffee is also acceptable;
however, the axillary method of measurement is the least reliable, and other
, methods should be used if available. If temporal equipment is available and the
client is diaphoretic, it is acceptable to measure the temperature on the neck
behind the ear, avoiding the forehead.
A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about
the disorder. The nurse plans to base the response on which information?
Rationale:
Hirschsprung's disease, also known as "congenital aganglionosis" or "megacolon,"
is the result of an absence of ganglion cells in the rectum and to varying degrees
upward in the colon
The nurse is reinforcing instructions about home safety measures regarding
medications and toxic substances to a parent. Which parent statements indicate
a need for further teaching? Select all that apply.
Rationale:
Home safety measures are very important to prevent unnecessary childhood
poisoning or death. Medicine should never be referred to as "candy." This could
tempt a child to try to eat it when the parents are not in the immediate vicinity.
Each medication should be correctly labeled and kept in a separate bottle to avoid
problems with identification of the medication actually taken. Toxic substances
should be labeled with green poison stickers and placed in a locked area out of
reach of children. The poison control center telephone number should be visible
near all telephones. Medications should be stored in childproof containers.
A client who experienced ventricular fibrillation has just been defibrillated.
Following the defibrillation, which action would the nurse take
immediately?
Rationale:
Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if
a normal rhythm has been restored, the heart pump needs to be reprimed to
provide improved cerebral blood flow to improve neurological outcome.
A mother of a 3-year-old is concerned because the child is still insisting on a bottle
at nap time and at bedtime. The nurse would make which suggestion to the
mother?
Rationale:
A toddler should not be allowed to fall asleep with a bottle because of the risk of
dental caries. If the bottle is allowed in bed, it should contain only water.
A client with a diagnosis of a recurrent major depression, exhibiting psychotic
features, is admitted to the mental health unit. In an attempt to create a safe
environment for the client, the nurse designs a plan of care that deals specifically
with which aspect of the client's disorder?
Rationale:
Altered thought process requires the nurse to create a plan of care that includes a
safe environment. Altered thought processes can include the presence of
hallucinations and delusions. A recurrent major depression with psychotic features
alerts the nurse that care must be planned to address both the major depression
and the psychosis. Psychosis is defined as a
