NGN/NCLEX PREP QUESTIONS/RATIONALES

NGN/NCLEX PREP QUESTIONS/RATIONALES The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - correct answer -The nurse should suspect Your Answer: hypokalemiaCorrect Answer: hypokalemia because of the Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T waves and occasional U waves Rationale:Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client's most recent serum potassium level and then contact the primary health care provider to report the findings and obtain prescriptions to treat the hypokalemic state. The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to this personal item? Click to highlight the correct answer from the options provided. - correct answer -The nurse should: (Select 1 option) Ask the client if the chain and medal can be removed during the procedure. Because: (Select 1 option) The chain and medal may have cultural significance. Rationale:Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body because of client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask the client if the item can be either removed temporarily or placed on another part of the body during the procedure if appropriate.While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have changed my mind. I don't want this surgery." Click to highlight the correct answer from the options provided. - correct answer -The nurse should: (Select 1 option) Cancel the surgery. Contact the surgeon. Discuss the client's concerns. Call the identified support person. Because: (Select 1 option) Client consent is required prior to any procedure. Further questions or concerns should be determined and addressed. Ethical considerations are important for a client undergoing surgery. The nursing scope of practice places limitations on how the nurse can respond. Rationale:If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can discuss the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored to specific needs. The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?For each action, click to specify whether the action would be: Indicated: an action that the nurse should take to resolve the problem Non-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problem Contraindicated: an action that could harm the client and should not be taken - correct answer - Collect identifying patient information Contraindicated Note the mental status of the client Non-essential Note primary and secondary diagnoses of clients affectedIndicated Note the type of IV catheter used Indicated Note the type of IV site dressings being used Indicated Note the medication types being infused Non-essential Note frequency of assessments of IV sites Indicated Note the expected duration of the IV site Non-essential Note care procedures to the IV site Indicated Note frequency of changing IV sites Indicated Rationale:Quality improvement, also known as performance improvement, focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed by evaluation of results based on the evidence-based practice protocols used. Collecting identifying client information is contraindicated because of confidentiality and is unnecessary in this quality improvement effort. Noting the mental status of the clients can be done but is not likely to address the The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw from the radial artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. How should the nurse interpret the finding? Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - correct answer -The test result is Your Answer: Abnormal Correct Answer: Abnormal becauseYour Answer: The time for color to return is prolonge Correct Answer: The time for color to return is prolonged Rationale:Failure to determine the presence of adequate collateral circulation before drawing an arterial blood gas specimen could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Another site needs to be selected for the arterial puncture, and the primary health care provider needs to be notified of the finding. The nurse has just received a client from the postanesthesia care unit (PACU) and is monitoring the client's vital signs. Click to highlight the current finding(s) that would be essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a finding, click the finding again. - correct answer -30 min ago: BP= 142/78 HR= 98 RR= 14 Temp= 37.2 C O2 sat= 95% 3L NC Current: BP= 95/54 (F/U correct) HR= 118 (F/U correct) RR= 18 Temp= 36.8 C O2 sat= 91% 3L NC (F/U correct) Rationale:Some of the client's vital signs are showing a significant change, particularly the blood pressure, heart rate, and oxygen saturation levels. The nurse should first compare the current vital signs to the set of baseline vital signs obtained when the client arrived to the unit. This provides information about how much of a change has occurred in these parameters. The nurse should quickly consider the following when determining the next action: (1) What is the client's condition? Is the client responding to stimuli? (2) Does the oxygen saturation increase if the client deep breathes? (3) Is the equipment working properly? (4) Is the correct equipment being used? (5) Is there a condition or procedure in the client's history that can be attributed to this change? (6) Are there environmental factors that could influence the change in the client's vital signs? (7) Does this change in the client necessitate contacting the surgeon? Given the significant changes from the baseline vital signs, and after checking the client and equipment to ensure it is working properly, the nurse should then determine that it is necessary to contact the surgeon to inform him or her of this change, especially considering that the client recently had surgery and there is a potential for bleeding. The nurse should determine if there is any sign of bleeding such as drainage on the dressing, bloody output in a surgical drain, or swelling in the surgical area suggestive of hematoma. The charge nurse should also be informed of the change in client status. A client has been diagnosed with chronic kidney disease. The nurse anticipates specific dietary prescriptions due to the risks associated with chronic kidney disease. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - correct answer -The nurse should note the client is Your Answer: On a fluid restriction Correct Answer: On a fluid restriction because Your Answer: Of the risk of hypervolemia Correct Answer: of the risk of hypervolemia To relieve the thirst, the nurse should instruct the client to Your Answer: Chew gum Correct Answer: Chew gum because Your Answer: it doesn't contribute to hypervolemia Correct Answer: it doesn't contribute to hypervolemia Rationale:The client with chronic kidney disease may be placed on fluid restriction because of decreased renal function and glomerular filtration rate, resulting in fluid volume excess. To allow the kidneys to rest, decreased fluid consumption may be indicated. When a client is placed on this restriction, increased thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, freezing fluids so they take longer to consume, adding lemon juice to allowed water to make it more refreshing, and gargling with refrigerated mouthwash. A client with a peripherally inserted central catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What should the nurse do?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problemNon-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problemContraindicated: an action that could harm the client and should not be taken - correct answer -Action Assess for feverNon-essential Assess for chest pain Indicated Assess for cyanosis Indicated Turn the client to the left side Indicated Position the client so the feet are lower than the head Contraindicated Administer oxygen Indicated Place the client on continuous vital sign monitoring Indicated Notify the primary health care provider Indicated Rationale:When a client has any type of central venous catheter, there is a risk for breaking of the catheter, dislodgement of a thrombus, or entry of air into the circulation, all of which can lead to an embolism. Signs and symptoms that this complication is occurring include sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia, and the nurse would assess for these findings. If this occurs, the nurse should clamp the catheter, place the client on the left side with the head lower than the feet (not the feet lower than the head) to trap the embolism in the right atrium of the heart, administer oxygen, and notify the primary health care provider. Continuous vital sign monitoring should also be done to note for changes in the client's condition. There is no reason for assessing for a fever at this time. The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfusion. The nurse suspects a transfusion reaction based on clinical presentation. Based on this scenario, select the initial clinical findings for each suspected condition - correct answer -Acute hemolytic reaction 1 Allergic reaction 3-4-5 Fluid volume overload 2Back pain(1) Difficulty breathing(2) Rash(3) Urticaria(4) Pruritis(5) Rationale:There are different types of blood transfusion reactions, including fluid volume overload, allergic reaction, and acute hemolytic reaction. In general, signs of an immediate transfusion reaction include the following: chills and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor and cyanosis; apprehension; tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. An acute hemolytic reaction is usually characterized by back pain initially. An allergic reaction is manifested by rash, urticarial, and pruritis as initial signs. Fluid volume overload often is noted by difficulty breathing in the early phase. The nurse is assessing an infant with clubfoot who is in a cast. The nurse notes the following clinical findings on assessment.Vital signs: Blood pressure 90/60 mm Hg Heart rate 112 beats per minute Respirations 24 breaths per minute Oxygen saturation 98% on room air Temperature 36.4° C (97.5° F) Musculoskeletal findings : Tissue distal to the cast is pale and edematous.The infant shows signs of pain with passive movement. Which actions should the nurse take? Select all that apply. - correct answer -1.Notify the surgeon 2.Administer topical pain medication 3.Administer anticoagulant medication 4.Contact the physical therapy department 5.Assess distal pulses on bilateral extremities 1 & 5Rationale:Compartment syndrome is a condition in which pressure increases in a confined anatomical space, leading to decreased blood flow, ischemia, and dysfunction of these tissues. This complication can occur with casts. Signs of this complication include unrelieved or increased pain in the limb; pale, dusky, or edematous tissue distal to the involved area; pain with passive movement; loss of sensation (paresthesia); and pulselessness (a late sign). In this scenario, the nurse should assess the distal pulses on bilateral extremities. Noting a difference between the 2 extremities is helpful in determining the presence of compartment syndrome. The nurse should contact the surgeon immediately if signs of neurovascular impairment are noted in a child with a cast or brace because of the risk of tissue ischemia and necrosis. Administering topical pain medication is not helpful because of the severity of the pain, and relief of the pressure is the priority and ultimately will relieve the pain. Administering anticoagulant medication does not address the problem of the pressure from the tight compartment. Contacting the physical therapy department is unnecessary and does not help to address this complication. The nurse is working in a long-term care facility that has a "no restraint policy." An assigned client is disoriented and unsteady and continually attempts to climb out of bed. Which interventions and supporting rationales are appropriate in this scenario? Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - correct answer -The nurse should Your Answer: Implement other safety strategies Correct Answer: Implement other safety strategies due to Your Answer: The risk for further injury with restraints Correct Answer: The risk for further injury with restraints Type in 3 safety strategies the nurse should implement: Any 3 of the following would be correct: Orienting the client and family to the surroundings Explaining all procedures Encouraging family and friends to stay Assigning confused or disoriented clients to a room near the nurses' station Providing appropriate stimuli to the client Maintaining toileting routines Eliminating bothersome treatments Using relaxation techniques Instituting an ambulation schedule Rationale:Many facilities implement a "no restraint policy," which requires health care workers to implement other safety strategies for clients who pose a risk for falls. These strategies include orienting the client and family to the surroundings; explaining all procedures and treatments to the client and family; encouraging family and friends to stay with the client as appropriate and using sitters for clients who need supervision; assigning confused and disoriented clients to rooms near the nurses' station; providing appropriate visual and auditory stimuli to the client, such as a nightlight, clock, calendar, television, or radio; maintaining toileting routines; eliminating bothersome treatments, such as tube feedings, as soon as possible; evaluating all medications that the client is receiving; using relaxation techniques with the client; and instituting exercise and ambulation schedules as the client's condition allows. Some agencies are instituting certain policies, such as hourly rounding, to ensure client safety. With hourly rounding, nurses and assistive personnel are required to check the client to address the 5 Ps—pro The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. In considering the child's developmental stage, the nurse should determine that this is an expected finding. Using Freud's psychosexual stages of development, identify the behaviors associated with the various stages that can be taught to the mother to alleviate her concerns. Select the behaviors that associate with Freud's psychosexual stages of development. - correct answer - Oral Correct Answer:4. Mouth-sucking and swallowing Anal Correct Answer:3. Withholding or expelling feces Phallic Correct Answer:1. Masturbation Latent Correct Answer:5. Little to no sexual motivation present Genital Correct Answer:2. Sexual intercourse Rationale:According to Freud's psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining genitalia, masturbating, and expressing interest in sexual concerns. The oral phase is associated with mouthsucking and swallowing, the anal with withholding or expelling feces, the latent with little to no sexual motivation, and genital with sexual intercourse. The nurse should alleviate the mother's concern by telling the mother that this behavior is normal. A pregnant client with diabetes mellitus asks the nurse about insulin needs during pregnancy. What information should the nurse provide to the client? Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - correct answer -Pregnancy places demands on Correct Answer: Carbohydrate...metabolism and causes insulin requirements to change. Maternal Correct Answer: Glucose... crosses the placenta, but Correct Answer: Insulin does not.... During the Correct Answer: First... trimester, maternal insulin needs decrease. During the Correct Answer: Second... and Correct Answer: Third... trimesters, increases in placental hormones cause an insulinCorrect Answer: Resistant... state, requiring a(n) Correct Answer: Increase... in the client's insulin dose. Due to the fact that the fetus produces its own Correct Answer: Insulin... and pulls Correct Answer: Glucose... from the mother, the mother is predisposed to Correct Answer: Hypoglycemic reactions.Rationale:The nurse should begin by explaining to the client that pregnancy places demands on carbohydrate metabolism and causes insulin requirements to change. The nurse should inform the client that maternal glucose crosses the placenta, but insulin does not. During the first trimester, maternal insulin needs decrease. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client's insulin dose. After placental delivery, placental hormone levels abruptly decrease and insulin requirements decrease. In addition, the fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions. The nurse is caring for a pregnant client in labor at 33 weeks' gestation, who experiences premature rupture of the membranes (PROM).Progress Notes: 1400 The nurse was notified regarding the lecithin/sphingomyelin (L/S) ratio of 1.5:11430 Fetal heart rate 134 beats per minute with variability What actions should the nurse take?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problem Non-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problem Contraindicated: an action that could harm the client and should not be taken - correct answer -Imminent delivery 3 Administration of corticosteroids 1 Hospitalization 1 Cesarean section on a specified date 2 Administration of magnesium sulfate 2 Administration of broad-spectrum antibiotics 1 Routine prenatal care3 Indicated(1) Non-essential(2) Contraindicated(3) Rationale:Management of PROM is done on an individualized basis, depending on certain risk factors. Labor and birth may be actively pursued if the PROM occurred between 34 and 36 weeks' gestation, as well as for women with PROM at 32 to 33 weeks' gestation if fetal lung maturity can be documented. PROM before 32 weeks' gestation is usually managed conservatively with hospitalization to prolong the pregnancy. Considering the progress for the infant in this scenario, the infant's lungs are considered to be mature when the L/S ratio reaches 2:1. A ratio of 1.5:1 is low and indicates that if the infant were born now, he or she may be at risk for complications related to lung immaturity. A fetal heart rate of 134 beats per minute is considered normal at this gestational age. Because of these reasons, imminent delivery would be considered contraindicated because the infant's lungs need to mature, and fetal well-being is noted on interpretation of the fetal monitor. Administration of corticosteroids would be indicated to promote fetal lung maturity in the event of imminent delivery due to other complications arising, such as intrauterine infection or umbilical cord compression as a result of PROM. Hospitalization, or daily monitoring, is indicated to monitor for these complications. A cesarean section scheduled for a specific date is non-essential, as this mother may still be able to have a vaginal delivery unless there are other indications for a cesarean section. Administration of magnesium sulfate is non-essential and is usually reserved for PROM be The nurse is caring for a client in the office setting who gave birth to a healthy infant 18 days ago by cesarean section after she had a prolonged labor and required artificial rupture of the membranes. Time: 1000 Vital signs: Blood pressure 108/74 mm Hg Heart rate 112 beats per minute Respirations 18 breaths per minute Oxygen saturation 98% on room air Temperature 101.2° F (38.4° C) Additional Assessment Findings:Reports fatigue, chills, nausea, and pelvic pain Tenderness noted on palpation of the abdomen and profuse lochia notedWhich actions should the nurse take? Select all that apply. - correct answer -1.Encourage increased water intake 2.Encourage hot tub use for comfort measures 3.Discuss a home exercise program with the client 4.Obtain a prescription for blood and urine cultures 5.Discuss initiating antibiotics with the obstetrician/gynecologist 6.Obtain a prescription for a complete blood count with differential 1 4 5 6 Rationale:A temperature of 100.4° F (38° C) is normal during the first 24 hours postpartum because of dehydration; a temperature of 100.4° F (38° C) or greater after 24 hours postpartum indicates infection. Therefore, if the temperature is 101.2° F (38.4° C) 18 days postpartum, the nurse should report the finding to the obstetrician/gynecologist. The likely diagnosis in this case is endometritis, which usually begins as a localized infection at the placental site, which can spread to the entire endometrium. Risk factors for this client include giving birth by cesarean section after a prolonged labor and artificial rupture of the membranes. The client should be encouraged to increase hydration, rest, and use pain relief measures. Although comfort measures such as rest, cool compresses, warm blankets, perineal care, and sitz baths may be helpful, sitting in a hot tub has the potential to worsen the infection. At this time, the client should be encouraged to rest rather than engage in a home exercise program. Blood cultures, urine cultures, intracervical or intrauterine cultures, complete blood count with differential, and sedimentation rate are helpful in diagnosing the problem. Management of this problem consists of intravenous broad-spectrum antibiotic therapy and supportive care. The nurse is performing an initial assessment on a newborn and notes that the newborn is experiencing slight tremors.Time: 0730Vital signs: Blood pressure64/41 mm HgHeart rate142 beats per minuteRespirations50 breaths per minuteOxygen saturation98% on room airTemperature36.4° C (97.5° F) Which actions should the nurse take? Select all that apply. - correct answer -1.Check the newborn's stool 2.Check the newborn's weight 3.Check the newborn's glucose level 4.Check the newborn's calcium level 5.Check the newborn for responsiveness 3 4 5 Rationale:Noting that the newborn's vital signs are normal, the nurse should consider some of the common causes of tremors in a newborn, as opposed to an infectious process. A tremor is noted to be repetitive movements of both hands with or without movement of the legs or jaw 2 to 5 times per second lasting more than 10 minutes. Slight tremors noted in the newborn may be a common finding but could also be a sign of hypoglycemia, hypocalcemia, or drug withdrawal. It can also be a sign of neurological damage, so this possibility should be addressed, although most tremors have no pathological significance. The nurse should determine the presence of tremors so that treatment can be initiated immediately. This finding should also be reported to the primary health care provider immediately. Checking the newborn's glucose level, calcium level, and level of responsiveness will provide information directly related to the potential cause of the tremors. The newborn's stool and weight patterns are not directly related to the tremors. A 4-year-old child admitted 1 day ago to the pediatric unit is suspected of having periorbital cellulitis of the right eye with associated impetigo. Which of the current findings would be essential to follow up on?Click to highlight the current finding(s) that would be essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a finding, click the finding again. - correct answer - ParameterCurrent8 hours ago24 hours agoBlood pressure92/64 mm Hg98/70 mm Hg99/70 mm HgPulse126 beats per minute120 beats per minute116 beats per minuteRespirations18 breaths per minute20 breaths per minute18 breaths per minuteOral temperature38.4° C (101.2° F)37.8° C (100° F)37.6° C (99.9° F) Laboratory testCurrent24 hours agoWhite blood cell18,400/mm3 (18.4 x 103/uL)15,200/mm3 (15.2 x 103/uL)Hemoglobin15.2 g/dL (152 mmol/L)15.0 g/dL (150 mmol/L)Hematocrit38% (0.38)39% (0.39) Cranial nerve testCurrent24 hours agoCranial nerve II20/20 left eye20/20 both eyes20/40 right eyeCranial nerve IIIExtraocular movements intact,Extraocular movements intact, no nystagmuspain associated with movements in right eye 2 4 5 9 11 Rationale:Periorbital cellulitis is an acute infection characterized by pain, erythema, and edema of the anterior eyelid and tissue surrounding the eye. The risk with periorbital cellulitis is that it can progress to orbital cellulitis and can threaten vision. Antibiotics should be prescribed, and intravenous antibiotics may be required depending on the clinical findings. If bacteremia is suspected, a complete blood count may be done, and vital signs will be monitored closely. Physical assessment should focus on visual acuity and extraocular movements. An increase in pulse rate, increase in temperature, increased white blood cell count, decreased visual acuity, and increased pain on extraocular movements in the affected eye are all findings that constitute a worsening of the condition and should be followed up on promptly to preserve vision. The nurse caring for a child with a diagnosis of leukemia receives a report from the laboratory indicating that the white blood cell count is 2000/mm3 (2.0 × 109/L) and the absolute neutrophil count (ANC) is 40% (0.40). Vital signs are unchanged from baseline and the child denies pain. The nurse determines that further actions are needed to care for this client based on this information. Fill in the correct missing information by selecting from the lists of options in the drop-down menus. - correct answer -ActionSupporting findingRationale Your Answer:1. Private roomCorrect Answer:1. Private room ANC less than 50% (0.50)Severe infection risk is presentAlcohol-based hand rub or hand washing Your Answer:2. ANC less than 50% (0.50)Correct Answer:2. ANC less than 50% (0.50) Severe infection risk is presentKeep fresh flowers out of the roomANC less than 50% (0.50) Your Answer:1. Can harbor bacteriaCorrect Answer:1. Can harbor bacteria 1 2 1 Rationale:A white blood cell count of 2000/mm3 (2.0 × 109/L) and an absolute neutrophil count of 40% (0.40) are indicative of a neutropenic state, and the child should be placed on neutropenic precautions. The absolute neutrophil count (ANC) is the standard of care in determining whether a child is in a neutropenic state and the need for protective isolation and other hygienic measures. If the ANC is less than 50% (0.50), a severe infection risk is present. Interventions include a private room; good hand-washing technique or use of an alcohol-based hand rub before entering the child's room and before touching the client or any belongings; ensuring that the child's room and bathroom are cleaned a minimum of once per day; limiting the number of people entering the child's room (no sick persons should enter the room); using strict aseptic technique for all invasive procedures; keeping fresh flowers and potted plants out of the room; and implementing a low-bacteria diet (no fresh fruits or vegetables or undercooked meats). A child suddenly vomits. The nurse takes the following actions to ensure safety. Select the Rationale for each Nursing Action. - correct answer -Nursing ActionsRationalPosition the child upright or on the side.Your Answer:1. This allows the child to maintain a patent airway.Correct Answer:1. This allows the child to maintain a patent airway.Perform oral suctioning.Your Answer:1. This allows the child to maintain a patent airway.Correct Answer:1. This allows the child to maintain a patent airway.Assess the character and amount of vomitus.Your Answer:3. This will provide information about possible causes of the vomiting episode.Correct Answer:3. This will provide information about possible causes of the vomiting episode.Assess the force of the vomiting.Your Answer:3. This will provide information about possible causes of the vomiting episode.Correct Answer:3. This will provide information about possible causes of the vomiting episode.Monitor intake and output and vital signs.Your Answer:2. This will be helpful in monitoring for complications of the vomiting episode.Correct Answer:2. This will be helpful in monitoring for complications of the vomiting episode. Rationale:If a child suddenly vomits, the nurse must maintain a patent airway. The child should be positioned upright or on the side to prevent aspiration. Suctioning equipment should be obtained, kept at the bedside, and used if needed to assist in maintaining a patent airway. The nurse should check the character and amount of the vomitus as this will provide information about possible causes of the vomiting episode. The force of the vomiting should be assessed because projectile vomiting may indicate pyloric stenosis or increased intracranial pressure, which are possible causes. The nurse should also monitor intake and output and vital signs to monitor for the complication of dehydration. The nurse is caring for an infant who underwent surgical repair of hypospadias. The infant weighs 4.5 kg.Progress Notes:1000: Urinary output 5 mL since Urinary output 4.5 mL1200 Urinary output 4.2 mL1300: Urinary output 3.0 mL1400: No urinary outputWhat actions should the nurse take?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problemNon-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problemContraindicated: an action that could harm the client and should not be taken - correct answer -Action Indicated(1) Non-essential(2) Contraindicated(3) Increase the rate of intravenous fluids.IndicatedNon-essentialContraindicatedFlush the intravenous line.IndicatedNon-essentialContraindicatedIncrease the number of feedings.IndicatedNonessentialContraindicatedPerform an abdominal assessment.IndicatedNonessentialContraindicatedPerform perineal hygiene.IndicatedNon-essentialContraindicatedContact the surgeon.IndicatedNon-essentialContraindicated 3 2 3 1 2 1 Rationale:Following surgical repair for hypospadias, there is a risk for kinks in the urinary diversion or stent placed during the procedure, as well as an obstruction caused by sediment. To detect this complication, the urinary output is monitored closely. The nurse should perform an abdominal assessment to assess for bladder distention and notify the surgeon if there is no urinary output for 1 hour because these findings may indicate this complication. Increasing the rate of intravenous fluids and increasing the number of feedings are contraindicated because these actions could result in producing more urine, which could worsen the bladder distention and potentially lead to perforation. In addition, these actions do not address the problem of urinary obstruction and also should not be performed without a prescription. Flushing the intravenous line and performing perineal hygiene are non-essential and will not address the problem although it would not cause harm. The charge nurse is preparing to make room assignments for the 8 clients below. What room assignments would result in a safe assignment for each client? Select an appropriate room and bed for each client. A maximum of two clients may occupy each room. Some clients may require a private room based on their diagnosis or current condition. - correct answer -(DELETE SELECT) 8-year-old female with confirmed respiratory syncytial virusSelect Room201 (Private)202-A202- B203-A203-B204-A204-B205 (Private)205 (Private)11-year-old male with sickle cell anemia in sickle cell crisisSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)203-B5-year-old female admitted for new-onset seizures scheduled for an electroencephalogramSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)202-A18-year-old female admitted for drug overdose who is on a legal hold because of a suicide attemptSelect Room201 (Private)202-A202- B203-A203-B204-A204-B205 (Private)201 (Private)10-year-old male awaiting a surgical consult for fractured humerusSelect Room201 (Private)202-A202-B203-A203-B204-A204-B205 (Private)204- B17-year-old male, status post laparoscopic cholecystectomySelect Room201 (Private)202-A202- B203-A203-B204-A204-B205 (Private)204-A7-year-old female admitted for complaints of abdominal pain awaiting surgical consult for suspected appendicitisSelect Room201 (Private)202-A202-B203- A203-B204-A204-B205 (Private)203-A18-year-old male admitted for observation following a head injury Rationale:In considering room assignments, the charge nurse needs to consider the gender of the clients as well as their diagnosis or current condition. It is also helpful to consider the age of the clients because when clients are assigned to semiprivate rooms, it is better if they are also close in age. The 8-year-old female with confirmed respiratory syncytial virus should be in 1 of the 2 private rooms because she requires droplet isolation and contact precautions. The 18-year-old female admitted for drug overdose who is on a legal hold should also be in a private room because she will require one-to-one monitoring and suicide precautions. The 10-year-old male awaiting surgical consult for The nurse is admitting a 42-year-old female client who is alone to the hospital unit with delirium. The nurse is reconciling the client's medications and finds a handwritten list of home medications in the client's wallet. The nurse transcribes the information that is available. Fill in the correct missing information by selecting from the lists of options in the drop-down menus. - correct answer - MedicationDose, Route, FrequencyDrug ClassIndication Your Answer:1. HydrochlorothiazideCorrect Answer:1. Hydrochlorothiazide 25 mg by mouth dailyThiazide diureticPrimary hypertensionBupropion ER150 mg by mouth twice dailyNorepinephrine-dopamine reuptake inhibitor Your Answer:4. DepressionCorrect Answer:4. Depression Norgestimate/ethinyl estradiol1 tab by mouth dailyHormonal contraceptive Your Answer:3. Prevention of pregnancyCorrect Answer:3. Prevention of pregnancy Alprazolam0.5 mg by mouth twice daily as needed Your Answer:1. BenzodiazepinesCorrect Answer:1. Benzodiazepines Generalized anxiety Rationale:Hydrochlorothiazide is a thiazide diuretic used to treat primary hypertension. Bupropion is a norepinephrine-dopamine reuptake inhibitor and is used to treat depression. Norgestimate/ethinyl estradiol is a hormonal contraceptive and is used to prevent pregnancy. Alprazolam is a benzodiazepine and is used on an as needed basis for the management of generalized anxiety.The nurse is performing an assessment on a 64-year-old African American client admitted with flank pain who has a history of type 2 diabetes mellitus, hypertension, and polycystic ovarian syndrome. The nurse notes the following clinical findings on assessment.Vital signs: Blood pressure142/84 mm HgHeart rate90 beats per minute (bpm)Respirations18 breaths per minute (bpm)Oxygen saturation98% on room airTemperature98.9° F (37.2° C) Laboratory test results: Serum glucose226 mg/dL (12.6 mmol/L)Serum potassium3.9 mEq/L (3.9 mmol/L)Serum creatinine2.2 mg/dL (194.3 mcmol/L)Hemoglobin, glycosylated (HbA1c)10.8%Serum lactic acid level25.2 mcg/dL (2.8 mmol/L)Urine glucosePositiveUrine ketonesNegativeUrine bilirubinNegativeUrine pH5.6 (5.6)Urine proteinModerateUrine specific gravity1.032 (1.032)Urine bacteriaMany Laboratory Physical assessment findings: NeurologicalPERRLA (Pupils equal, round, reactive to light and accommoda - correct answer -1. Initiate a referral for nephrology 2. Administer an as needed antianxiety medication 3. Assess for neurological changes in the extremities 4. Assess for a history of bacterial infections and antibiotic use 5. Discuss with the primary health care provider about initiating a dietician referral 6. Collaborate with the primary health care provider on prescribing further laboratory testing 1 3 4 5 6 Rationale:Given the client's present and past medical history, as well as other clinical findings, it is appropriate to initiate a referral to nephrology. The client's creatinine level is elevated, and there are abnormal findings on the urinalysis, including urine glucose, protein, and bacteria. The client also has flank pain. The client may be experiencing complications of type 2 diabetes mellitus and also is likely experiencing a urinary tract infection. The client is also showing signs of an ascending urinary tract infection, and septicemia should be a concern. Assessing for neurological changes in the extremities is an appropriate action as this is a common complication of poorly controlled diabetes mellitus (serum glucose of 226 mg/dL [12.6 mmol/L] and HbA1c is 10.8%). Assessing for a history of bacterial infections and antibiotic use is appropriate because this, along with a consistently elevated blood glucose level, predisposes the client to further bacterial infections such as urinary tract infection. A dietician referral would be appropriate for this client given the fact that her diabetes is poorly controlled as evidenced by the blood glucose level and HbA1c level. Further laboratory testing is likely indicated, specifically blood and urine cultures, to determine the extent of the disease and to guide further interventions in the care of this client. A client who is bedbound and incontinent has been diagnosed with heart failure exacerbation. The nurse anticipates specific prescriptions due to the risks associated with heart failure. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - correct answer -The nurse should note the client is Your Answer: On a fluid restrictionCorrect Answer: On a fluid restriction because Your Answer: of the risk of hypervolemiaCorrect Answer: of the risk of hypervolemia To relieve the thirst, the nurse should instruct the client to Your Answer: use lemon swabsCorrect Answer: use lemon swabs because Your Answer: it doesn't contribute to hypervolemiaCorrect Answer: it doesn't contribute to hypervolemia The nurse notes that in order to effectively monitor diuretic therapy, a prescription for Your Answer: an indwelling urinary catheterCorrect Answer: an indwelling urinary catheter should be anticipated because Your Answer: it allows for monitoring of a therapeutic effectCorrect Answer: it allows for monitoring of a therapeutic effect Rationale:The client with heart failure exacerbation may be placed on fluid restriction because of altered cardiac output and overall cardiac function, resulting in fluid volume excess. To allow the heart to rest, decreased fluid consumption may be indicated. When a client is placed on this restriction, increased thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, using lemon swabs, freezing fluids so they take longer to consume, adding lemon juice to water to make it more refreshing, and gargling with refrigerated mouthwash. The client with heart failure exacerbation will likely be on diuretic therapy to manage the fluid volume excess. To effectively monitor for a therapeutic effect, the nurse should anticipate a prescription for an indwelling urinary catheter if the client is incontinent because the excess fluid is excreted by way of the kidneys in the form of urinary output. An increase in urinary output