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NEW QUESTION # 275
A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?
- A. Low-protein diet
- B. High-cholesterol diet
- C. Low-sodium diet
- D. Increased fluid intake
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) A high-protein diet is usually indicated because protein is excreted in urine. Protein restriction is usually prescribed with severe azotemia. (B) The kidneys usually enlarge in these children, and sodium and water are retained. (C) Fluid restriction may be ordered to help reduce edema; however, monitoring for dehydration is indicated. (D) A high-cholesterol diet would not be indicated for any child, especially one with elevated blood pressure.
NEW QUESTION # 276
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:
- A. Elevate right lower extremity with pillows propped under the knee
- B. Assess for edema and heat of the right leg
- C. Instruct him to rub the cramp out of his leg
- D. Assess for pain with plantiflexion
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.
NEW QUESTION # 277
A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:
- A. 12 noon
- B. 10:30 AM
- C. 9:30 AM
- D. 4:00 PM
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 2-4 hours after administration. (D) This is too late for peak action to occur.
NEW QUESTION # 278
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
- A. Knowledge deficit related to treatment regimen
- B. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract
- C. Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss
- D. Fluid volume deficit related to vomiting and nasogastric tube drainage
Answer: B
Explanation:
Section: Questions Set E
Explanation:
(A) Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
NEW QUESTION # 279
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
- A. Complete blood count
- B. Arterial blood gases
- C. Serum electrolytes
- D. 12-Lead ECG
Answer: C
Explanation:
(A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe.
NEW QUESTION # 280
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
- A. Give the child 1 cup of water to induce vomiting.
- B. Give the child 10 mL of syrup of ipecac with a sip of water.
- C. Bring the child to the ER immediately.
- D. Give the child 15 mL of syrup of ipecac.
Answer: C
Explanation:
Section: Questions Set B
Explanation:
(A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration.
NEW QUESTION # 281
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?
- A. High protein and high fat
- B. High protein and high calorie
- C. High calorie and high carbohydrate
- D. Low-fat 2-g sodium diet
Answer: C
Explanation:
(A) A high-protein diet is contraindicated in hepatic disease. (B) High carbohydrates provide high-caloric content to prevent tissue catabolism. (C) A low-fat 2-g sodium diet is a cardiac diet; however, a low-fat diet would be beneficial. (D) A high-protein and high-fat diet is contraindicated in hepatic disease.
NEW QUESTION # 282
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
- A. Increased PaCO2
- B. Decreased PaO2
- C. Increased HCO3
- D. Decreased base excess
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation.
Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.
NEW QUESTION # 283
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking "the blue pill" (haloperidol) in the morning and evening, and "the white pill" (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Taking her medication with food or milk
- B. Taking the benztropine in the morning
- C. Doubling the daily dose of benztropine
- D. Decreasing the haloperidol dosage for a few days
Answer: B
Explanation:
(A) Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (B) To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. (C) This response is an appropriate independent nursing action. Because motorrestlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. (D) Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
NEW QUESTION # 284
Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?
- A. Verapamil (Isoptin)
- B. Epinephrine (Adrenalin)
- C. Amrinone (Inocor)
- D. Propranolol (Inderal)
Answer: D
Explanation:
Explanation
(A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through stimulation. (D) Propranolol, esmolol, and labetalol are all - blocking agents, which can increase airway resistance and cause bronchospasms.
NEW QUESTION # 285
A client presented herself to the mental health center, describing the following symptoms: a weight loss of
20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to "fatigue," and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
- A. Severe depression
- B. Psychotic depression
- C. Severe anxiety
- D. Deep depression
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A client in deep depression would have been brought to the mental health center and would not be physically able to seek help for herself. (B) She is not manifesting psychotic symptoms in her behaviors.
(C) The client's symptoms are more indicative of depression than anxiety. (D) Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.
NEW QUESTION # 286
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
- A. Notify the physician
- B. Auscultate fetal heart rate
- C. Assess the client's respirations
- D. Transfer to delivery suite
Answer: B
Explanation:
(A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother. (B) The physician is notified after the nurse completes an assessment of the mother's and fetus's conditions. (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver.
NEW QUESTION # 287
Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?
- A. Surgically repaired herniated lumbar disk
- B. Brain tumor or other space-occupying lesion
- C. History of frequent urinary tract infections
- D. History of mitral valve prolapse
Answer: B
Explanation:
Section: Questions Set F
Explanation:
(A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.
NEW QUESTION # 288
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. Pneumonia
- B. A tension pneumothorax
- C. Pulmonary embolus
- D. An asthma attack
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production.Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. (D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
NEW QUESTION # 289
A complication for which the nurse should be alert following a liver biopsy is:
- A. Jaundice
- B. Shock
- C. Hepatic coma
- D. Ascites
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.
NEW QUESTION # 290
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Maintaining seizure precautions
- B. Applying ankle and wrist restraints
- C. Increasing sensory stimuli
- D. Restricting fluid intake
Answer: A
Explanation:
Explanation
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
NEW QUESTION # 291
A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this information, which drug might the nurse expect to be discontinued?
- A. Garamycin (Gentamicin)
- B. Phenytoin (Dilantin)
- C. Timolol maleate (Blocadren)
- D. Prednisone
Answer: B
Explanation:
(A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastic anemia. The drug most commonly linked to aplastic anemia is chloramphenicol (Chlormycetin).
NEW QUESTION # 292
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:
- A. Assist the client to the bathroom and provide cues to stimulate urination
- B. Massage the fundus until firm
- C. Administer methergine IM
- D. Remove the retained placental fragments
Answer: B
Explanation:
Explanation
(A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage.
Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
NEW QUESTION # 293
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
- A. Catheterize the client and reassess the uterus
- B. Administer analgesics as ordered to relieve discomfort
- C. Begin IV fluids and administer oxytocic medication
- D. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia
Answer: D
Explanation:
Explanation
(A) Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the "living ligature." (B) A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. (C) Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. (D) The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.
NEW QUESTION # 294
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be kept NPO for 24 hours before the exam
- D. Explain that his vital signs will be checked frequently after the test
Answer: D
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
NEW QUESTION # 295
Signs and symptoms of an allergy attack include which of the following?
- A. Wheezing on inspiration
- B. Prolonged expiration
- C. Increased respiratory rate
- D. Circumoral cyanosis
Answer: B
Explanation:
(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs.
NEW QUESTION # 296
After a liver biopsy, the best position for the client is:
- A. Right lateral
- B. Prone
- C. High Fowler
- D. Supine
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral position would allow pressure on the liver to prevent bleeding.
NEW QUESTION # 297
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