1. ANSWER A. Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating more frequent, smaller meals decreases heartburn resulting from the reflux of acidic secretions into the lower esophagus. Pregnant women need adequate hydration (fluids) and fiber to prevent constipation.
2. ANSWER A. The nurse should call the oncology unit to institute a transfer. The nurse handling chemotherapy agents should be specifically trained. It is an unwise use of nursing resources to send a nurse from one unit to administer medications to a client on another unit. It is better to centralize and send the clients who need chemotherapy to one unit. Even if the pharmacy mixes the agent, the drug must be administered by a nurse who is trained to do so.
3. ANSWER B. After surgery, the most important nursing diagnosis should be Risk for Infection. Surgery involves an incision, which is at risk for infection. The infant with this type of procedure does have discomfort, which can be relieved with acetaminophen. Pain would be an important nursing diagnosis but not the priority. The infant may be in arm restraints or have the cuff of the sleeve pinned to the diaper or pants. It is important that the infant not touch the incision line or disrupt the sutures. There is no indication of Impaired Parenting. The parents would be reacting normally with a first reaction of shock.
4. ANSWER A. An appropriate outcome for clients with rheumatoid arthritis is that they will adopt self-care behaviors to manage their joint pain, stiffness, and fatigue and be able to perform their activities of daily living. ROM exercises can help maintain mobility, but it may not be realistic to expect to be able to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for clients to understand the importance of taking their prescribed drug therapy even if their symptoms have abated.
5. ANSWER D. Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy, unless it is an individualized need for a given client. Topical antibiotics are applied after the therapy, not before submersion in the water.
6. ANSWER A. Hepatitis B immune globulin is given as prophylactic therapy to individuals who have been exposed to hepatitis B. Interferon has been approved to treat hepatitis B. Hepatitis B surface antigen is a diagnostic test used to detect current infection. Amphotericin B is an antifungal.
7. ANSWER A. When examining the tympanic membrane of a child younger than 3 years of age, the nurse should pull the pinna down and back. For an older child, the nurse should pull the pinna up and back to view the tympanic membrane.
8. ANSWER C. In the compensatory stage of shock, the client will exhibit moderate tachycardia. If the shock continues to the progressive stage, decreased urinary output, hypotension, and mental confusion will develop as a result of failure to perfuse and ineffective compensatory mechanisms. These findings are indications that the body’s compensatory mechanisms are failing.
9. ANSWER B. Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia. Polyuria is associated with this diuretic, not urinary retention. Confusion and diaphoresis are not side effects of hydrochlorothiazide.
10. ANSWER A. The ability to remember an old song is related to long-term memory, which persists after short-term memory is lost. Therefore, the nurse would respond by providing the son with this information. Stating that the nurse is happy to hear about the change and that the client is getting better is inappropriate and inaccurate. This statement ignores the issue of long-term versus short-term memory. Telling the client not to get his hopes up because the improvement is only temporary is inappropriate. The information provided does not indicate that the client has expressive aphasia, which would be suggested by the statement that the client can’t talk to the son.
11. ANSWER A. A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.
12. ANSWER A. The client is in a crisis and has a high anxiety level. Holding the client’s hands and encouraging the client to slow down and take a deep breath conveys caring and helps decrease anxiety. Telling the client to calm down or stop worrying offers no concrete directions for accomplishing this task. It is unknown from the data who was at fault in the accident. Therefore, it would be inappropriate for the nurse to state that it wasn’t the client’s fault.
13. ANSWER C. Many women who acquire gonorrhea are asymptomatic or experience mild symptoms that are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but they are more likely not to realize they have been affected with a disease. Gonorrhea is easily transmitted to all women and can result in serious consequences such as pelvic inflammatory disease and infertility.
14. ANSWER D. Tingling and numbness of the toes would be the earliest indication of circulatory impairment. Inability to move the toes and cyanosis are later indicators. Complaints of cast tightness should be investigated, because cast tightness can lead to circulatory impairment; it is not, however, an indicator of impairment.
15. ANSWER C. The nurse notifies the physician because a drooping of one side of the face or a “one-side cry” is associated with facial nerve damage. Additionally, the mother’s delivery record and history need to be reviewed for a possible cause. Craniotabes is a softening of the skull bones. The bones are so soft that indentation from the pressure of an examining finger can occur. Meningitis, or inflammation of the meninges, is associated with a rigid neck. Other symptoms may include lethargy, poor sucking reflexes, weak cry, seizures, and apnea. Skull fracture is not associated with a drooping facial appearance. Rather, it would be evidenced by a crack in the skull bone, possibly accompanied by leaking cerebrospinal fluid.
16. ANSWER C. The client should be encouraged to report any painful urination or urinary retention. Lesions are usually present for 17 to 20 days. The client is capable of transmitting the infection even when asymptomatic, so a barrier contraceptive should be used. Forcing fluids will not stop the lesions from forming.
17. ANSWER B. Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.
18. ANSWER A. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client’s change in mental status, tachypnea, and tachycardia are all indicative of a possible pulmonary embolism. The nurse should promptly notify the doctor of the client’s condition. Administering a sedative without further evaluation of the client’s condition is not appropriate. There is no need to elicit a positive Homan’s sign; the client is already diagnosed with a deep vein thrombosis. Increasing the intravenous flow rate may be an appropriate action, but not without first notifying the physician.
19. ANSWER C. The nurse should always double-check a large dose of insulin before administering it. A nurse should always listen to the client; if a client who has been taking insulin for a long time suggests that the insulin dose is not right, the nurse should recheck the physician’s order. Comparing insulin doses of other clients has no bearing on a particular client’s dose. The nurse should not use “U” or “u”; the nurse should specify “unit” to avoid errors.
20. ANSWER B. Coping with the chronic tinnitus of Ménière’s disease can be very frustrating. Providing background sound, such as music, can help camouflage the low-pitched, roaring sound of tinnitus. Maintaining a quiet environment can make the sounds of tinnitus more pronounced. Avoiding caffeine and nicotine is recommended, because this can decrease the occurrence of the tinnitus. However, avoiding these substances does not help the client with coping with tinnitus when it occurs. Taking a sedative does not affect the sounds of the tinnitus.