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After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? a)It is typically seen with breech births. b)It usually lasts a day or two before resolving. c)It is unusual when the brow is the presenting part. d)Surgical intervention may be necessary to alleviate pressure. - b)it usually lasts a day or two before resolving Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary. A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client's laboratory reports to determine which potential complication of the client's symptoms? a)hyperalbuminemia b)thrombocytopenia c)hypokalemia d)hypercalcemia - c)hypokalemia Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response? a)"What has your neighbor been doing that bothers you?" b)"How long have you been hearing these terrible voices?" c)"We won't let your neighbor visit, so you'll be safe." d)"What exactly are these terrible voices saying to you?" - d)"What exactly are these terrible voices saying to you?" Explanation: The nurse needs to collect additional information about the client's report about hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first. Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? a)The nurse dries from finger tips down toward elbows. b)The nurse dries from forearms up toward fingers. c)The nurse keeps hands lower than elbows while washing. d)The nurse uses at least 3 to 5 mL of liquid soap. - b)The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices. Which fetal presentation is most favorable for birth?a)vertex presentation b)transverse lie c)frank breech presentation d)posterior position of the fetal head - a)vertex presentation Explanation: Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie presentation (when the neonate is in a horizontal position across the birth canal) requires a cesarean birth. Frank breech presentation, in which the buttocks present first, can make for a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis bone. A client enters the crisis unit complaining of increased stress from studies as a medical student. The client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when taken concomitantly with alprazolam? a)levodopa b)famotidine c)diphenhydramine d)norgestrel - c)diphenhydramine Explanation: Using benzodiazepines with other central nervous system depressants such as diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel. A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with functioning at work. How can the nurse best instruct this client about the relief of fatigue? a)Explain that fatigue will improve during the second trimester. b)Instruct the client to take at least two rest breaks during the workday. c)Instruct the client to get at least 9 hours of sleep each night.d)Instruct the client to modify work hours during the first trimester. - b)Instruct the client to take at least two rest breaks during the workday. Explanation: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. For the working pregnant client, it is advisable to take two 10- to 15- minute breaks within an 8-hour workday. While at home the client should nap or rest if she feels sleepy or tired. People need different amounts of sleep to help them feel rested. Telling the client to get 9 hours is a good suggestion, but it isn't helpful or practical if the client needs normally needs significantly more or less than that. In general, 7-8 hours is adequate. Modifying work hours can be suggested, but many times this is not something within the client's control. Fatigue will most likely improve during the second trimester, but that does not address the client's immediate concerns. Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? a)It determines fetal lung maturity. b)It is noninvasive using real-time ultrasound. c)It will correlate with the newborn's Apgar score. d)It requires the client to have an empty bladder. - b)It is noninvasive using real-time ultrasound. Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity. Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound requires the mother to have a full bladder. Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? a)Change the dressing. b)Elevate the head of the bed.c)Test the fluid for glucose. d)Notify the health care provider (HCP). - c)test the fluid for glucose Explanation: Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid. Excessive fluid leakage should be reported to the HCP. The nurse should not change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon. Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures. The nurse should notify the HCP after testing the fluid for glucose. When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? a)It can be adjusted to a position of comfort. b)It is used to lift the child. c)It adds strength to the cast. d)It is necessary to turn the child. - c)it adds strength to the cast Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast. Upon initial assessment of a postoperative client, the nurse identifies that the I.V. infusion is different from the solution ordered by the physician. What is the first action the nurse should take? a)Discontinue the I.V. at the insertion site. b)Assess the client, call the physician, and then hang the ordered solution. c)Let the current IV. bag infuse while calling the physician to confirm the order. d)Replace the current I.V. with the ordered IV after the current I.V. finishes. - b)Assess the client, call the physician, and then hang the ordered solutionExplanation: This scenario is the same as any medication error. The client must be assessed, the physician must be notified, and the correct solution should be given to the client. The other answers are incorrect because they do not ensure that the client will receive appropriate follow-up care for a medication error. When an epidural catheter is used for postoperative pain management, what should the nurse do? a)Assess but not disturb the epidural dressing. b)Change the epidural dressing daily. c)Change the epidural dressing daily only if it is wet. d)Use strict aseptic technique when handling the epidural catheter. - a)Assess but not disturb the epidural dressing Explanation: The nurse should assess but not disturb the epidural dressing because the catheter can be easily dislodged and organisms can easily be transmitted into the central nervous system. The nurse should not have to change the dressing at all if a waterproof dressing is applied over the epidural site. Even with strict aseptic technique, a drain into a sterile cavity is a direct route for transmission of organisms and places a client at increased risk of infection, and the nurse should not handle the dressing or the catheter. A neonate with heart failure is being discharged home. When teaching the parents about the neonate's nutritional needs, what should the nurse explain? a)Fluids must be restricted. b)Decreased activity level should reduce the need for additional calories. c)The formula should be low in sodium. d)The neonate may need a more calorie-dense formula. - d)The neonate may need a more caloriedense formula. Explanation: Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fluid intake will decrease calories needed for growth. These neonates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growthand development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the health care provider (HCP) . The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? a)hamburger, salad, and milkshake b)baked liver, green beans, and coffee c)spaghetti with tomato sauce, salad, and coffee d)fried chicken, green beans, and skim milk - c)spaghetti with tomato sauce, salad, and coffee Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a lowcholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol. A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? a)a 2-year-old child who nearly drowned 2 days earlier b)a 19-month-old infant who had surgery for a fractured tibia 12 hours ago c)a 6-month-old infant who has gastroenteritis and vomits every 30 minutes d)a 17-month-old infant who lost consciousness 2 hours earlier because of a head injury - a)a 2-yearold child who nearly drowned 2 days earlier Explanation: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical. The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse?a)Ask the client to state name and birthdate. b)Give client paper and pencil with which to write name and birthdate. c)Recall the client's facial features to verify the client's identity. d)Ask two staff members to state the name of the client in the room. - a)Ask the client to state name and birthdate. Explanation: The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write his or her name and birthdate as a client has ataxia, not apraxia. Ataxia involves muscle movement, typically in the arms and legs. Apraxia involves speech. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity. The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy? Select all that apply. a)taping all IV tubing connections b)wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material d)wearing a long-sleeved gown when administering chemotherapy - b)wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material Explanation: Nurses preparing and administering chemotherapy wear gloves and a disposable, longsleeved gown. Antineoplastic agents are disposed of as hazardous material and gloves are always worn when handling the excretions of clients who have received chemotherapy. It is not appropriate to tape IV tubing connections; antineoplastic agents are administered using Luer lock fittings on all intravenous tubing to minimize the risk of exposure from needle stick injury. Which sound should the nurse expect to hear when percussing a distended bladder? a)Hyperresonance.b)Tympany. c)Dullness. d)Flatness. - c)Dullness. Explanation: A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present. The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply. a)The spouse places soiled dressing supplies in the kitchen garbage can. b)Disinfectant spray is used on the table where dressing supplies are prepared. c)Clean gloves are used for wound dressing removal. d)Sheets with wound drainage are washed in lukewarm water. e)Dressing supplies are placed in a clean, dry location. f)Routine hand hygiene is performed before and after care. - a)The spouse places soiled dressing supplies in the kitchen garbage can. d)Sheets with wound drainage are washed in lukewarm water. Explanation: Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing Which action by the nursing assistant would require immediate intervention by the nurse? a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the roomb)assisting a preschool-age child in the bathroom with the door closed c)transporting a newborn in a bassinet from the mother's room to the newborn nursery d)removing a toddler from a sleeping mother's bed to the crib - a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room Explanation: The nurse supervising a nursing assistant will need to intervene when a nursing assistant restrains a client requiring one-on-one observation to leave the room. It should be reinforced with the nursing assistant to call for a replacement for the time needed to leave the client. Assisting a preschooler in a bathroom is appropriate for that age group. Transporting an infant in a bassinet is appropriate and within the scope of the nursing assistant's job. Removing the toddler from the mother's bed to the crib is appropriate. Cosleeping is dangerous for the child, and the mother should be educated on the risks. Which client should the nurse assess first?