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NEW QUESTION 166
A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
- A. Lung immaturity
- B. Intrauterine infection
- C. Neural tube defect
- D. Intrauterine growth retardation (IUGR)
Answer: A
Explanation:
(A) At about 30-32 weeks' gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.
NEW QUESTION 167
A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:
- A. Prevents administration of other drugs
- B. Prevents entry of air into tubing
- C. Prevents inadvertent administration of a large amount of fluids
- D. Prevents phlebitis
Answer: C
Explanation:
Explanation
(A) A volume control set has a chamber that permits the administration of compatible drugs. (B) Air may enter a volume control set when tubing is not adequately purged. (C) A volume control set allows the nurse to control the amount of fluid administered over a set period. (D) Contamination of volume control set may cause phlebitis.
NEW QUESTION 168
A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:
- A. Glucocorticoid followed by the bronchodilator
- B. Bronchodilator followed by the glucocorticoid
- C. Alternate successive administrations
- D. According to the client's preference
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. (B) Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. (C) Inac- Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. (D) Client teaching regarding the use and effects of inhalers will promote client understanding and compliance.
NEW QUESTION 169
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
- A. Challenge client's behavior immediately with steps to prevent injury to self or others.
- B. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting.
- C. Leave the aggressive client to himself or herself, and take other clients away.
- D. Approach the client on a continuum of least restrictive care.
Answer: D
Explanation:
(A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
NEW QUESTION 170
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
- A. Oxytocin
- B. Magnesium sulfate (MgSO4)
- C. Ampicillin
- D. Tetracycline
Answer: C
Explanation:
Explanation
(A) Oxytocin is prescribed to stimulate uterine contractions. (B)
MgSO4is a central nervous system depressant prescribed to prevent
and control convulsions related to preeclampsia. (C) Ampicillin
is a penicillin derivative with no known teratogenic effects.
This is the safest antibiotic during pregnancy. (D) Tetracycline
stains teeth yellow and is not as safe as ampicillin during pregnancy.
NEW QUESTION 171
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Notify the physician immediately.
- B. Administer an antiemetic as necessary.
- C. Hold the child's discharge for 1 hour.
- D. Discharge the child as the physician ordered.
Answer: A
NEW QUESTION 172
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?
- A. Altered growth and development related to decreased intake of food
- B. Decreased cardiac output related to ineffective pumping action of the heart
- C. Altered nutrition: less than body requirements related to inability to take in adequate calories
- D. Activity intolerance related to imbalance between oxygen supply and demand
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
NEW QUESTION 173
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased level of consciousness
- B. Increased rate and depth of respirations
- C. Increased peripheral vasodilation
- D. Increased perception of pain
Answer: C
Explanation:
(A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
NEW QUESTION 174
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
- A. Decreased breath sounds on the left and chest pain with movement
- B. Rhonchi and frothy sputum
- C. Crackles and paradoxical chest wall movement
- D. Wheezing and dry cough
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema.
(D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.
NEW QUESTION 175
A dose of theophylline may need to be altered if a client with COPD:
- A. Is concurrently on cimetidine for ulcers
- B. Is allergic to morphine
- C. Has a history of arthritis
- D. Operates machinery
Answer: A
Explanation:
Section: Questions Set B
Explanation:
(A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.
NEW QUESTION 176
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. "HIV can be transmitted to an unborn infant."
- B. "HIV is a virus that is easily transmitted by casual contact."
- C. "Condoms reduce the transmission of HIV."
- D. "HIV is a virus transmitted by sexual contact."
Answer: B
Explanation:
Explanation/Reference:
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 177
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
- B. The cord clamp be left on until the cord stump separates
- C. Petrolatum be placed around the cord after the sponge bath
- D. A belly binder be applied to prevent umbilical hernia
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
NEW QUESTION 178
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child's mother for the home treatment of croup?
- A. Give large amounts of clear liquids if drooling occurs.
- B. Take him in the bathroom, turn on the hot water, and close the door.
- C. Place him near a cool mist vaporizer and encourage crying.
- D. Give him a dose of antihistamine.
Answer: B
Explanation:
Explanation
(A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child.
NEW QUESTION 179
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. 0.06 mL
- B. 0.38 mL
- C. 2.7 mL
- D. Information given insufficient to determine the amount of atropine to be administered
Answer: B
Explanation:
Explanation
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
NEW QUESTION 180
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Preventing infection
- B. Providing pain relief
- C. Maintaining an adequate level of hydration
- D. O2 therapy
Answer: C
Explanation:
Section: Questions Set D
Explanation:
(A) Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process.
Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
NEW QUESTION 181
A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14- year-old with some of the missing items. The best response of the nurse is to:
- A. Imply to him that you doubt his involvement in the incident and request his denial
- B. Confront him openly in group and request an apology
- C. Request that he explain to the group why he took personal items from peers
- D. Approach him when he is alone to inquire about his involvement in the incident
Answer: D
Explanation:
(A) This answer is incorrect. There is no proof that he removed the missing items. (B) This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. (C) This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. (D) This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
NEW QUESTION 182
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
- D. Pain, pallor, pulselessness, paresthesia, and paralysis
Answer: D
Explanation:
(A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five "P's": pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
NEW QUESTION 183
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:
- A. Biparietal diameter is at the level of the ischial spines
- B. Presenting part is 2 cm above the level of the ischial spines
- C. Presenting part is 2 cm below the level of the ischial spines
- D. Biparietal diameter is 5 cm above the ischial spines
Answer: C
Explanation:
(A) Station is the relationship of the presenting part to an imaginary line drawn between the
ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.
NEW QUESTION 184
On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
- A. Supine with feet elevated
- B. Sitting in a chair
- C. Lying on the left side
- D. High Fowler
Answer: D
Explanation:
(A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema.
NEW QUESTION 185
A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must follow the rules of the unit?
- A. "You are not being fair to the other clients by getting them involved in your deviant behavior."
- B. "Break the rules, all you want, but don't get caught again!"
- C. "It is not easy, but the rules must be followed so that everyone can get a fair chance."
- D. "If you do not follow the rules, you will be transferred to the closed, locked unit."
Answer: C
Explanation:
Explanation
(A) This statement acknowledges that it is difficult but is not threatening or punitive. (B) This statement is threatening and describes specific punishment for further deviant behavior. (C) This response elicits shame by blaming her for involving others. (D) This response gives her permission to break the rules but indicates that getting caught is wrong.
NEW QUESTION 186
A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?
- A. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces.
- B. Question the mother and find out what the pediatrician has told her about the baby's condition.
- C. Tell the mother that this is not a serious condition.
- D. Call the orthopedist and request that he come to see the baby now.
Answer: B
Explanation:
(A) The nurse should call the orthopedist after assessing the mother's knowledge. (B) The nurse must first assess the knowledge of the parent before attempting any explanation. (C) The nurse should assess the mother's knowledge of the baby's condition as the first priority. (D) This answer is correct, but the priority is B.
NEW QUESTION 187
In the coronary care unit, a client has developed multifocal premature ventricular contractions. The nurse should anticipate the administration of:
- A. Furosemide
- B. Digoxin
- C. Nitroglycerin
- D. Lidocaine
Answer: D
Explanation:
Explanation
(A) Furosemide is a loop diuretic. (B) Nitroglycerin is a vasodilator. (C) Lidocaine is the drug of choice to treat ectopic ventricular beats. (D) Digoxin slows down the electrical impulses and increases ventricular contractions, but it does not rapidly correct ventricular ectopy.
NEW QUESTION 188
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