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298 Cards in this Set

  • Front
  • Back

hypocalcemia causes _____ qt intervals

prolonged

hyokalemia causes______ p waves

flattened p waves and dysrhythmias

hypercalcemia causes______ qt intervals

shortened

hyperkalemia _____ the qrs complex

widens

client who had a tia should ______ salt intake

reduce dietary sodium intake



client who had a tia should ______potassium intake

increase

client who had a tia should _________fiber intake

increase

client who had a tia should limit alcohol to __________

no more than 2 servings men


no more than 1 serving women

an ________ hematocrit indicates hypovolemia

elevated

indications of hypovolemia

weak pulse,tachycardia, hypotension, tahcypnea, slow cap refill, elevated bun, increased urine specific gravity, decreased urine output

low urine specific gravity indicates ______

hypervolemia

children who have cystic fibrosis have an elevated ________

sweat chloride

manifestations of celiac disease

foul, fatty, frothy stools


steatorrhea

clubbing of fingers indicates _______ disorders

cardiovascular due to chronic hypoxemia of the tissues

______ results from liver dysfunction

jaundice`

varenicline

smoking cessation


assess first for mood changes



setraline cannot be taken with

st johns wort

eating ________vegetables is a safer choice than eating fresh vegetables for a client with neutropenia
canned and frozen

otitis media and smoking corolation
smoking promotes adherence of resp pathogens to the lining of middle ear space. can prolong inflammation and impedes drainage from the ear

immediately following injury and for at least 48 hr the child who has a lower extremity fracture and a fiberglass cast should

elevate the affected limb above the heart to prevent edema and pain and to promote venous return

steven johnson syndrome can manifest as a ______ within 2-8 weeks of treatment of lamotrigine

rash

administration of ________ can help prevent addisonian crisis

hydrocortisone

addisons disease causes

adrenal gland hypfunction and inadequate production of glucocorticoids

tb will be communicable for _____ from the start of medication therapy

2-3 weeks
an infant of 18 months old should have ____ teeth

12
A nurse in the labor and delivery suite is planning care for a group of four clients. Which of the following clients should the nurse see first?
A client who is in active labor and has late decelerations on the fetal heart monitor’s strip Late decelerations are nonreassuring patterns that reflect impaired placental exchange or placental insufficiency. Because late decelerations indicate fetal hypoxia, the nurse should assess and intervene immediately by changing the client’s position, administering oxygen, increasing IV fluids, and preparing for the possibility of an immediate caesarean birth.
A nurse is planning teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse plan to include?
The importance of colonoscopy screening starting at age 50 years old. Screening examinations for colorectal cancer are secondary prevention (an action that promotes early detection of disease).
Providing dietary teaching to prevent colorectal cancer is a ________prevention (an action to prevent the development of a disease).
primary
A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?
Explain that it is against policy to share access codes and refer the resident to his supervisor.

Staff should never share access codes and passwords nor allow people who do not have their own access code to use the system. Doing so is a breach of federal guidelines for data security and client confidentiality.
The most common adverse effects of acarbose, an alpha-glucosidase inhibitor, are _________
gastrointestinal. They include diarrhea, abdominal distention and cramping, and flatulence.



A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder
This describes basal cell carcinoma, a slow-growing skin tumor that results from sun exposure in clients who have fair skin. Basal cell carcinomas are usually pale in color and either pearly or flaky in appearance.
An irregularly shaped brown lesion with light blue areas on the neck



this is an example of what type of skin cancer
Malignant melanoma, the leading cause of death from skin cancer, is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned people at the greatest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck, and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion, with irregular borders in hues of blue white, and red tones.
facial swelling or generalized edema can indicate
pregnancy-induced hypertension and preeclampsia and should be reported to the provider.
Spotting with urination could indicate either vaginal spotting or hematuria, both of which should be
reported to the provider.

adverse effect of ethambutol



Loss of red/green color discrimination




Ethambutol is an antitubercular medication that impairs ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the medication.
A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)?

headache


DDS is a CNS disorder. It is a complication that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood’s pH. Clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes headache, nausea, vomiting, decreased level of consciousness, seizures, and restlessness. When it is severe, clients progress to confusion, seizures, coma, and death.
Phenelzine is an MAOI. Clients taking MAOIs must avoid foods that contain ________due to a dangerous food–drug interaction.
tyramine

foods high in tyramine include those that are processed and aged, such as luncheon meats and cheeses. This menu selection does not contain food high in tyramine; therefore, this selection indicates an understanding of the teaching.
Thyrotoxicosis can result if a client takes too much levothyroxine. Manifestations include
chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, and diaphoresis. The client should notify the provider if any of these manifestations are present.
Factors that can make a hearing aid whistle are a
poor seal with the ear mold, an ear infection, excessive wax in the ear canal, improper fit, or a malfunction.
A hearing aid might whistle if the volume is too
high, not too low.
A nurse is assessing a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection?
Candidiasis, or oral thrush, results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS.
A nurse is assessing a client who has AIDS and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider
Decreased hemoglobin
Cystitis is an
inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women who are at risk for UTIs should avoid tub baths because they increase the risk for infection. The nurse should teach the client to take showers instead of tub baths.
Donepezil might slow the progression of
early-onset Alzheimer’s disease, but is not indicated for autism spectrum disorder.
Transmission of HIV from a woman to her infant can occur during
pregnancy, delivery, or through breastfeeding. Though it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants.
The ELISA test is unreliable for testing for HIV in infants under
18 months of age because of false positive results due to maternal antibodies. The results are reliable, however, for clients 18 months of age and older.
An adverse effect of doxycycline, a tetracycline antibiotic, is
photosensitivity. The skin reacts abnormally to light, especially ultraviolet radiation or sunlight. Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.
Doxycycline is more likely to cause _______ than constipation.
diarrhea
Ototoxicity is an adverse effect of _______. Doxycycline is a tetracycline antibiotic.
aminoglycosides
Doxycycline is more likely to interfere withthan________ visual acuity.
color vision
A nurse is teaching self-administration of NPH insulin to a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include?
Rotate injection sites within the same area.
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes?
Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With the cleft in the palate, these infants could develop poor speech habits.


lasik surgery For some clients, vision is clear an hour after surgery; however, it can take up to
4 weeks for complete healing and optimal vision
A nurse is observing a client who has schizophrenia and is in the dayroom when another client asks him if two items of clothing match. He replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations?
The nurse should identify that this client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts that lead from one to another
A nurse is assessing a client who reports an acute visual disturbance and describes it as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?
Retinal detachment
A cataract is a
clouding that develops in the lens of the eye over time. Cataracts slowly impair vision and, without treatment, lead to blindness. Manifestations include decreased color perception and blurry vision.
Angle-closure glaucoma
Angle-closure (acute) glaucoma results from a sudden shift in the position of the iris of the eye that blocks the outflow of aqueous humor. This leads to an acute onset of a severely painful rise in intraocular pressure. Angle-closure glaucoma is an emergency. Manifestations include a sudden onset of severe pain around the eyes and face, reduced vision, colored halos, and headaches.
Macular degeneration
Macular degeneration results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. Manifestations include gradual, mild to moderate reduction of central vision.
A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following information about the function of cochlear implants?
Cochlear implants work by directly stimulating nerve fibers in the cochlea.
Bone conduction hearing aids, conduct
sound waves through the skull to the inner ear.
An implantable piezoelectric device converts
vibrations in the eardrum and ossicles to signals a sound processor then amplifies. A driver then transmits them to the inner ear for sound perception.
A nurse is discussing medication administration for an older adult client with a newly licensed nurse. The nurse should identify that, due to physiological changes of aging, older adult clients might need dosage adjustments due to an increase in which of the following parameters?
Body fat
Aging causes physiological changes in all organ systems. Tissue composition changes the nurse should be aware of include
an increase in adipose tissue, a decrease in lean body mass, and a decrease in total body water. The increase in fatty tissue causes increased storage of lipid-soluble medications and lowers plasma levels of those medications.
A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client
The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from his mouth, tilt his head back slightly, and then open his mouth. Next, he should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway. After holding his breath for 10 seconds, the client should resume his usual breathing pattern.
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client’s plan of care?
A client who is immobile is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function.
The nurse should plan to inspect the client’s pin sites at least
every 8 to 12 hr due to the risk for infection.
A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?
The nurse should use the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication.



Tell me about your favorite video game."
A nurse is planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse plan for this client?
Walking with a staff member



The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff.
Infection is a risk after a ventriculoperitoneal shunt insertion, especially 1 to 2 months after placement. The parents should report
fever, vomiting, seizure activity, and decreases in responsiveness, as these can indicate infection.
Oral glucocorticoids are more likely to s
low linear growth in children.Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (the client’s airways) resulting in an decreased risk for adrenal suppression.
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client’s bedside and perform which of the following verification procedures?
compare the medical record number and name on the MAR with the client’s identification band.







The Joint Commission requires the use of two client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client’s identification band.
Nausea, vomiting, and epigastric distress are common manifestations of
MI.
With pancreatitis, laboratory results typically show elevated
amylase within 12 to 24 hr. This level remains elevated for 2 to 3 days.
Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for
latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.
A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG) in the morning. Which of the following information should the nurse provide the client?
Shampoo your hair before the procedure, and don’t put any styling products on it afterward."



An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges the nerve cells in the brain release. So that the electrodes will adhere to the scalp, the client’s hair has to be clean and free of oil and hair-care products
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse?
A leak within the ventilator's circuitry
When a client is coughing or trying to talk, the ventilator must exert greater force to deliver the preset volume of oxygen. This increase in resistance of the airway against the machine can trigger a
high-pressure alarm, not a low-pressure alarm..
Resistance during delivery of a specific volume of oxygen to the client triggers the ventilator’s
high-pressure alarm, not a low-pressure alarm. A possible cause is decreased lung compliance due to disorders such as COPD.
The activation of a high-pressure alarm indicates an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions could generate a
high-pressure alarm, not a low-pressure alarm



Collard greens are a good source of

lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. They also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects.
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings should indicate to the nurse that the AAA is expanding?
An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities, that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.
Difficulty seeing numbers on highway signs is most likely due to
myopia, or nearsightedness, in which the cornea curves sharply and the focal point is in front of the retina. Objects in the distance are blurry, but those close up are clear.
A nurse is caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication?
INR 3.0



Warfarin is an anticoagulant that prevents thrombus formation in susceptible clients. The INR measures its effectiveness. For most clients taking warfarin, an INR of 3.0 indicates effective therapy.
The aPTT test monitors the effectiveness of the anticoagulant
heparin, not warfarin.
Taking any nitrates, such as isosorbide and nitroglycerin, is a contraindication for
sildenafil, a medication that treats erectile dysfunction. Taking it concurrently with nitrates can cause life-threatening hypotension.
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?
Stop the teaching and check with the surgeon about informed consent
A nurse is caring for a client who is at 38 weeks of gestation and in the active phase of the first stage of labor. The nurse notes two late decelerations of the fetal heart rate during the last five contractions. Which of the following actions should the nurse take?
Assist the client to a lateral position.



A late deceleration is a variation in the fetal heart rate that results from uteroplacental insufficiency. Side-lying positioning helps improve uteroplacental blood flow.
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take
Apply continuous pressure to the lower part of his nose
A nurse at a family planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following information should the nurse plan to include in the teaching?
Use spermicidal jelly whenever you use your diaphragm."

A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device.
Women should insert their diaphragm up to
6 hr before vaginal intercourse.
Women should wait at least
6 hr after vaginal intercourse before removing the diaphragm. Removal prior to 6 hr increases the chance of pregnancy by allowing semen to enter the uterus.
Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from
an abusive injury
Opioids are more effective for residual limb pain rather than phantom limb pain. Additionally, meperidine is not recommended for chronic pain because
using it long-term can cause accumulation of a toxic metabolite.
Tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own
6 to 12 months after insertion.
Clients whose thyroid hormone levels are high have increased
protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with an increased appetite, it is often difficult to meet energy demands, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake.
A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) with mild manifestations. The nurse should expect that the provider will prescribe which of the following medications?
Tolvaptan



SIADH is a disorder of water intoxication due to the inappropriate, continuous secretion of antidiuretic hormone by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment of SIADH includes fluid restriction, sodium replacement with small amounts of 0.9% sodium chloride, and a vasopressin antagonist, such as tolvaptan. Tolvaptan promotes the excretion of water, which helps to correct the fluid imbalance in clients who have SIADH.
Chlorpropamide is an antidiabetic agent that also has antidiuretic effects that would worsen the manifestations of SIADH. It is used to treat .
diabetes insipidus, not SIADH
The nurse should identify sudden oliguria as an indication of an
acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This type of reaction results from the client’s antibodies reacting to the transfused RBCs.
Hypotension due to circulatory shock is an indication of an .
intravascular hemolytic reaction
A fever is an indication of an
intravascular hemolytic reaction.

assertive personnel can perform


delegation
non invasive interventions such as skin care, rom exercises, ambulation, grooming, hygeine measures,

lpn can perform


delgation

all things ap can perform as well as dressing changes, suctioning, urinary catheterization, and medication administration, can review teaching plans that were initiated by the rn

rn


delegation

responsible for assessment and planning of care, initiating teaching, administering medications intravenously

electrolyte imbalance ekg changes


hypocalcemia

prolonged st segment


prolonged qt interval
electrolyte imbalance ekg changes

hypercalcemia

shortened st segment


widened t waves
electrolyte imbalance ekg changes

hypokalemia

st depression


shallow, flat or inverted t wave


prominent u wave

electrolyte imbalance ekg changes


hyperkalemia

tall peaked t wave


flat p waves


widened qrs complexes


prolonged pr interval

electrolyte imbalance ekg changes


hypomagnesemia

tall t waves


depressed st segment
electrolyte imbalance ekg changes

hypermagnesemia

prolonged pr interval


widened qrs complexes

when pt experiences acid base imbalance,monitor the _______ level closely

potassium


k moves in or out of the cells in an attempt to maintain acid base balance




acidosis: k moves out of cell, causes elevated k levels




alkalosis: k moves into the cell, causes decreased k levels

in acidosis the rr and depth

increase in an attempt to exhale acids

in alkalosis the rr and depth

decreases, co2 is retained to neutralize and decrease strength of excess bicarb

developmental therory

defines consistencies in how families change `

authoritarian dictorial parenting

parent control the childs behavior and attitudes through unquestioned rules and expectations

family assessment includes

med history, support systems, stressors, environment, structure, family characteristics

rr


newborn -1 yr

30-35

rr


1-2 yr

25-30

rr


2-6yr

21-25

rr


6-12 yr

19-21

rr 12 yr and older



16-19

pulse


newborn

80-180

pulse


1wk to 3 month

80-220

pulse


3m -2 yr

70-150

pulse


2-10 yr
60-110

10 yr and older


pulse

50-90

infant b/p

65-78/


41-52

moro reflex

up until 4 months

plantar grasp

up until 8 months

stepping reflex

up until 4 weeks

tonic neck reflex

until 3-4 months

expected results of nurse checking a childs trigeminal nerve

clenching teeth together tightly


detecting facial touches with eyes closed



trigenminal nerve in infants

rooting and sucking reflexes

vagus nerve infants

has intact gag reflex

vagus nerve child

has intact gag reflex


can detect sour sensations on back of tongue

Activated charcoal is________________ to an adolescent who has ingested a corrosive substance, because it can infiltrate any tissue that is burned.

not administered
Injury by a _________ is more extensive than by a __________
corrosive liquid

corrosive solid
A child who has an elevated blood lead level should have an adequate intake of
calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.

babinski reflex

present until age of 1 year

extrusion

causes infant to spit out food placed on tongue


absent by age of 4 months

moro

extension of the arms and flexion of the elbows in response to sudden jarring, followed by flexion and adduction of the extremities


disappear at age 3-4 months

The first dose of the MMR immunization is administered at
12 to 15 months of age, and the TDaP immunization is administered at 11 to 12 years of age.
the TDaP immunization is administered at
11 to 12 years of age.
The recommended immunizations for a 2-month-old infant include
Hib and IPV.
The Hib immunization series consists of _______doses, depending on the immunization used, and at a minimum is administered at the ages of ___________.
3 to 4

2 months, 4 months, and 12 to 15 months
The IPV immunization series consists of ______ doeses and is administered at the ages of
4 doses

2 months, 4 months, 6 to 18 months, and 4 to 6 years.
A ________infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury.
stationary
To prevent a burn injury, the temperature of the water heater should not exceed
49° C (120° F).
The development of sexual characteristics prior to the age of
9 years in boys, and 8 years in girls, is an indication of precocious puberty and requires further evaluation.
The deciduous teeth are being shed at this age, starting with the lower central incisors at approximately the age
of 6.
The birth weight should triple by
12 months of age. By 30 months of age, the birth weight should be quadrupled.

complete primary detention
This is an expected finding in a 30-month-old toddler. At this age, the toddler should have all 20 deciduous teeth.
Male clients are at _____________risk for hospitalization-related stress compared to female clients.
increased
Children between the ages of_____________ are more vulnerable to the stress of hospitalization than a 10-year-old child.
6 months and 5 years
Children who experience multiple and frequent hospitalizations are at an ___________risk for stress-related reactions to hospitalization.
increased
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take?
Rock the child in long rhythmic movements.

The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements.

Ask the child to hold his breath and then blow it out slowly.
This is an example of a distraction strategy.
Ask the child to describe a pleasurable event.
This is an example of guided imagery.
Td is recommended for wound prophylaxis in children
ages 7 years and older. Td is also recommended every 10 years after 18 years of age.
DTaP is used to provide immunity against diphtheria, tetanus, and pertussis in infants and children under the age of
7 years. DTaP is not recommended for wound prophylaxis.
Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine
Tdap is given to adults/adolescents who have completed the initial DTaP immunization series, but have not yet received an adult tetanus booster (Td). The minimum age for Tdap is 10 years; however, children between the ages of 7 and 10 years who have not received all recommended doses of DTap should be given a dose of Tdap. Tdap is not recommended for wound prophylaxis.
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take?

Wash and dry the infant's genitalia and perineum thoroughly.


This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device.



It is acceptable for the nurse to place the infant’s penis and scrotum inside the collection bag in order to ensure a snug fit and prevent leaking.
A toddler’s use of the appropriate pronoun when referring to self does not occur until
30 months of age.
A toddler develops an intense focus and interest in pictures at
15 months of age.
"Your child should be able to scribble spontaneously using a crayon at the age of
15 months."
at the age of ___________ the toddler should be able to make strokes imitatively.
18 months,
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most commonfood allergy in children?
Cow’s milk
___________children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought.
Preschool-age
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay?
Inability to vocalize vowel sounds
The infant should begin vocalizing vowel sounds at the age of
7 months, and by the age of 10 months, be able to say at least one word.
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions?
Supine
The flexed sitting position may be used during a
lumbar puncture.
A semi-recumbent position is used when
performing a gavage feeding. The client's head and chest should be elevated.
The side-lying position may be used during a
lumbar puncture.
The startle reflex disappears by the age of
4 months, and the crawl reflex disappears around the age of 6 weeks.
At the age of 5 months, the infant should have no
head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.
At the age of 5 months, the infant can visually follow a dropped object, but the infant is unable to pick the object up until around the age of
6 months.
The infant should be able to roll from her back to her side at the age of
4 months.
Infants should ____________their birth weight by 6 months and _________their birth weight by 12 months.
double

triple

Legs crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the legs
flex at the knees when the infant is supine. Crossed and extended legs when supine is a finding associated with cerebral palsy.
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.
MMR and varicella immunizations are either
administered during the same visit, or at least 1 month apart.
A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
"I can give my child acetaminophen for discomfort associated with the immunization."

Parents can give acetaminophen for minor discomforts such as low-grade fever and local tenderness resulting from the administration of the immunization.

2 month immunization

diptheria and dtap, rv, ipv, hib, pcv, and heb b

4 month immunization

dtap, rv, ipv, hib, pcv

6 months immunization

dtap, ipv (6-18m), pcv, and heb b (6-18m) rv, hib

4-6 yr old


immunization

tdap, mmr, ipv

3-6 yr old immunization

influenza yearly


live attenuated influenza vaccine by nasal spray

child should hop on one foot at age

4

child should ride tricycle at age

3

child should jump rope at age

5

child should through ball overhead at age

4

preschool child should have intake of _____ calories

1800

preschool child should have _____ servings of fruit/vegetable per day

5

preschool child should have ____ protein

13-19

preschool age children should have ____% of satuated fat daily

10%

11-12 yr child should receive what immunization

tdap, tiv, mcv4


hpv

flacc scale

2m-7yrs

faces scale

3yrs and older

numeric scale

5yr and older

Taking ciprofloxacin with__________ can impair the absorption of the medication, reducing its effectiveness.

antacids

The nurse should plan to provide prophylaxis through immunization to _________workers, who have a high risk of exposure to smallpox.
mortuary
"Smallpox can be transmitted via
transmitted through bodily fluids, such as blood or vomit."

via contaminated objects, such as the bedding and clothing of an infected client, is a known route for the transmission of smallpox.


via inhalation of droplets, such as from the cough of an infected client, is a known route for the transmission of smallpox.
A nurse is performing a community assessment in a rural setting. Which of the following types of health care should the nurse recognize is most likely to be absent in this setting?
Tertiary care
West Nile virus is not transmitted through pets, but can be transmitted from
person to person through blood products, breast milk, or organ transplantation.
A nurse is providing teaching to a community group who lives near a nuclear power plant about safety related to radiation exposure. A client asks, "Isn’t there something we should have on hand in case of a nuclear disaster?" The nurse should recognize that the client is referring to which of the following substances?
Potassium iodide, if taken in time and at the appropriate dosage, blocks the thyroid gland’s uptake of radioactive iodine. It can reduce the risk of thyroid cancers and other diseases that might otherwise be caused by exposure to radioactive iodine that might be dispersed in a severe nuclear accident.
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

absent bowel sounds with distention
To prevent the risk of care-giver injury, the nurse should never insert
fingers into the mouth of an unresponsive client.

steps to performing abdominal assessment

inspect


auscltate


percuss


palpate
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
I should expect my heart rate to take longer to return to normal after exercise as I get older."

Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.
Decreased gastric emptying is an expected finding in
older adults.
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The nurse acts as a witness to attest that it is the client’s signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh.

The nurse should auscultate for the blood pressure at the popliteal artery.


The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed.


The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
Remove the restraints one at a time.
The nurse should ensure that the restraints are removed and range-of-motion exercises are performed every
2 hr.
The nurse should not tie the restraints to the side rails because
this can injure the client if the rails are lowered.
Restraint prescriptions can only be written for a
24-hr period and cannot be a PRN prescription.
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."



While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.
Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least
15 to 20 seconds.
__________ is used to clean the inner cannula.
Half-strength peroxide solution
Cotton ball particles can be aspirated into the
tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients’ commitment to a long-term goal of weight loss?
Attempt to increase the clients’ self-motivation
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45° angle to the bed.
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night.







The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding.

The nurse should offer an ice collar, not a heating pad, to ease


the child’s pain.


Milk products, such as ice cream and pudding, are usually avoided because they coat the mouth and throat, causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
The mitral valve is located in the
fifth intercostal space just medial to the midclavicular line.
The pulmonic valve is located in the
second intercostal space to the left of the sternum.
The tricuspid valve is located in the
fifth intercostal space to the left of the sternum.
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.
The nurse should instruct the client to consume a minimum of _______of fluid to prevent constipation.
1,500 mL
The nurse should instruct the client to increase consumption of __________ rather than refined-fiber foods.
coarse-fiber and whole grains,
The nurse should not recommend intake of daily_______because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.
laxatives
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
Screening groups of older adults in nursing care facilities for early influenza manifestations.
Secondary prevention is focused on
preventing complications of an illness or providing care to prevent illness from becoming severe.
Administering influenza immunizations is an example of _____________ for people who are healthy but in danger of becoming ill.
primary prevention
Educating clients about the dangers of influenza is an example of ___________for people who are healthy but in danger of becoming ill.
primary prevention
Finding rehabilitation programs for older adults who have complications from influenza.



This is an example of__________ prevention, which tries to prevent complications and help people recover from an existing illness.

tertiary
A pericardial friction rub has a_______ sound heard best with the diaphragm of the stethoscope at the _________

High-pitched scratching, grating, or squeaking leathery




eft sternal border



A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward
Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be_________ if the cuff is too small for the client.
falsely high
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.



If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.

The nurse should assess all peripheral pulses to determine the
equality of blood perfusion to the extremities.
The nurse should use a Doppler ultrasound stethoscope for a pulse that is
nonpalpable or very difficult to palpate.
The nurse should assess pedal pulses to determine
circulation in the client’s lower extremities.
For a client who has decreased circulation in the leg, evaluating
pedal pulses is critical in order to determine adequate blood supply to the foot.
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing.



The nurse should remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges.
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device.
The nurse should cleanse the drain opening with ___________after opening it to decrease entry of microorganisms.
an alcohol wipe
_________occurs when the closing of the wound using sutures or staples occurs at the time the incision is made and the suture line edges become well-approximated during healing.
Primary intention
__________ includes using sutures to close an open wound at a later date after the wound drains and starts to heal.
Tertiary intention

A skin graft is placed over the wound bed.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?
Granulation tissue fills the wound during healing.
The nurse should instruct the client to change the ostomy pouch every________ to avoid skin breakdown around the stoma.
3 to 7 days
The nurse should instruct the client to cleanse the skin around the stoma with_________
warm water, because using soap can leave a residue on the skin and cause poor adherence of the pouch adhesive.
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client’s surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
A halo of erythema on the surrounding skin



The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open.
The nurse should direct the irrigation solution onto the
lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.
The nurse should allow at least________ between suctioning passes to prevent hypoxia and to hyperventilate the client.
1 min
The nurse should pull the suction catheter back________ when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning.
1 cm (0.5 in)
The nurse should instruct the client to hold her breath for ________after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia.



incentive spirometry

3 to 5 seconds
The nurse should instruct the client to breathe________for short periods of time between each cycle of breaths, to reduce hyperventilation and fatigue.



incentive spirom
normally
The nurse should instruct the client to repeat the patterns for ________ breaths every hour while awake, which helps to prevent the risks of atelectasis and pneumonia.
10 to 20 breaths
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Hold the linens away from the body and clothing.
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
Pinch the NG tube while removing the tube.
The nurse should instruct the client to_________ during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents.
take a deep breath and to hold it
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
"I am going to listen to your abdomen."



A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client’s abdomen to determine the presence of bowel sounds before clear liquids can be administered.
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?
The nurse should secure with tape the client’s indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.
The nurse should plan to collect the sputum specimen when the client
arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.
Purulent exudate drainage on the client’s dressings is
thick yellow, green and brown drainage and usually indicates wound sloughing or infection.
Serosanguineous exudate drainage on the client’s dressings indicates
plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged and watery drainage.
Serous exudate drainage on the client’s dressings indicates
plasma from the blood and appears clear to light yellow, and is watery.
Sanguineous exudate drainage on the client’s dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings.
RBCs from the plasma that appears bright red on the dressings.
The nurse should weigh the client on
arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments, and on the same carefully calibrated scale (balanced to zero before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid.
The nurse should plan to have the client’s weight taken wearing
the same type of clothing each to provide an accurate reading and to avoid embarrassment.
The nurse should calibrate the scales to 0 each
day or before each use to provide accurate information.
The nurse should hold the eye dropper_________ from the lower conjunctival sac to protect the cornea of the eye from injury by preventing the tip of the dropper touching the eye.
1 to 2 cm (0.4 to 0.8 in)
The nurse should drop the eye medication in the
outer third of the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.
The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for
30 to 60 seconds to keep the medication from running down the duct or out of the eye.

enema

The nurse should position the client on the __________position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema.
left side in the Sims’
The nurse should insert the tip of the tubing ________along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa.
7 to 10 cm (3 to 4 in)
An elevated ________indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.
hematocrit
____________is an antitubercular medication that impairs ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the medication.
Ethambutol
DDS is a CNS disorder. It is a complication that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood’s pH. Clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes
headache, nausea, vomiting, decreased level of consciousness, seizures, and restlessness. When it is severe, clients progress to confusion, seizures, coma, and death.
Thyrotoxicosiscan result if a client takes too much levothyroxine. Manifestations include
chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, and diaphoresis. The client should notify the provider if any of these manifestations are present.



Candidiasis, or oral thrush, results from the overgrowth of Candida albicans, an __________fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS
opportunistic
An adverse effect of doxycycline, a tetracycline antibiotic, is
photosensitivity. The skin reacts abnormally to light, especially ultraviolet radiation or sunlight. Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.
The initial goal of therapy for DKA is a blood glucose level below
240 mg/dL.
Manifestations of retina detachment include a
sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field
Macular degeneration results in a
loss of vision in the center of the visual field (the macula) because of damage to the retina. Manifestations include gradual, mild to moderate reduction of central vision.
Angle-closure (acute) glaucoma results from a sudden shift in the position of the iris of the eye that blocks the outflow of aqueous humor. This leads to an acute onset of a
severely painful rise in intraocular pressure. Angle-closure glaucoma is an emergency. Manifestations include a sudden onset of severe pain around the eyes and face, reduced vision, colored halos, and headaches.
A cataract is a
clouding that develops in the lens of the eye over time. Cataracts slowly impair vision and, without treatment, lead to blindness. Manifestations include decreased color perception and blurry vision.
Cochlear implants work by
directly stimulating nerve fibers in the cochlea.
Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for
latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.
Collard greens are a good source of
lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. They also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects.
Difficulty seeing numbers on highway signs is most likely due to __________or nearsightedness, in which the cornea curves sharply and the focal point is in front of the retina. Objects in the distance are blurry, but those close up are clear
myopia,
presbyopia
With presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.
Warfarin is an anticoagulant that prevents thrombus formation in susceptible clients. The INR measures its effectiveness. For most clients taking warfarin, an INR of
3.0 indicates effective therap
A late deceleration is a variation in the fetal heart rate that results from uteroplacental insufficiency. Side-lying positioning helps improve uteroplacental blood flow.

a
beta human chorionic gonadotropin is positive

pregnancy

a

a