Which statement by the nurse would correctly characterize essential hypertension? Forty percent of the American adult population is affected by hypertension. Essential hypertension is more severe in men than women. American <b>blacks</b> develop hypertension at an earlier age than whites but have a lower mortality rate. Given newer screening devices, most persons with hypertension are now being detected. Hypertension is considerably more severe in men than women and tends to occur more frequently at an earlier age. Answer 1 is incorrect because currently it is estimated that 20 to 25 million Americans (about 10% of the population) have hypertension. The low percentage is due largely to non-detection related to the slow onset and lack of specific symptoms in its early stages. Answer 3 is incorrect because the prevalence in every age group is higher for American blacks than for whites. Likewise, the severity of hypertension in black men is three times that in white men and the severity in black women is almost six times that experienced by white women. Mortality rates for the American black population with hypertension are twice those of the white hypertensive population. Answer 4 is incorrect because in many individuals hypertension goes undetected and untreated. Use a process of elimination?. In assessing a woman's reasons for suspecting she maybe 3 months pregnant, the most relevant question for the nurse to ask would be: Are you currently taking oral contraceptives? When was your last menstrual period? How much weight have you gained? Have you been pregnant before? The date of the woman's last period is the most relevant question to ask in performing the initial assessment, because it will assist the nurse in making a preliminary determination of possible pregnancy. Answer 1 is incorrect: whether the woman is presently taking oral contraceptives may be relevant, but it would be more pertinent to assess what general type of birth control the couple may be using and if they have been using it effectively. Answers 3 and 4 are incorrect: whether she has been pregnant before and how much weight she has gained are both relevant to performing the assessment, but not essential to determining whether she is pregnant at the present time. Choose the answer that meets the condition of the stem: to find out if she is pregnant now. Review presumptive, probable, and positive signs of pregnancy. When caring for a child who has experienced severe burn(s) of the oral cavity and possibly of the esophagus, pharynx, and larynx, the primary nursing intervention should be: Observe for symptoms of shock. Check airway for signs of obstruction. Maintain adequate hydration by offering small amounts of clear liquid. Initiate intravenous therapy immediately. Adequate oxygenation is foremost in importance. Answer 1 is incorrect because the primary intervention should be to ensure a patent airway, followed by observation for signs and symptoms of shock. Answer 3 is incorrect: liquids would be contraindicated because of the child's burns and possible shock. Answer 4 is incorrect because a medical order would be needed to initiate intravenous therapy. Patent airway is always the priority of care? A patient with a history of substance abuse is admitted to the hospital after being brought there by police; the patient had been found on school property running around in the nude with several other students. The patient appeared to be hallucinating. The nurse who admits this patient to the unit should be primarily concerned with: Providing a general orientation to the unit. Maintaining a quiet environment. Taking precautions against seizures. Taking vital signs every 4 hours. Patients who abuse drugs react in various ways, depending on the amount and type of drug taken, the combination of drugs, and individual factors such as overall general health and age. However, seizures are common shortly after the ingestion of drugs such as narcotics and stimulants. Seizures may also accompany the withdrawal from drugs. Answer 1 is incorrect because the patient is not in touch with reality. Answer 2 is incorrect because maintaining a quiet environment is of secondary importance to taking precautions against seizures. Answer 4 is incorrect because taking vital signs is of secondary importance to taking precautions against seizures. However, vital signs should be taken as soon as possible, to establish a baseline, and retaken at least every 1-2 hours thereafter until the patient is stable. Primary concern is seizure prevention. A patient with a history of severe abdominal cramping and vomiting a moderate amount of blood arrives at the emergency department. The nurse's primary concern should be: Observing for signs and symptoms of shock. Immediately paging the physician on call. Filling out the appropriate assessment tool. Immediately administering CPR. Because the patient has experienced some gastric bleeding, he or she should be observed closely for symptoms of shock. Answer 2 is incorrect because paging the physician is secondary to the close monitoring of the patient's vital signs for symptoms of shock. Answer 3 is incorrect because completing the appropriate assessment tool may be done when the patient is under less stress. Answer 4 is incorrect because CPR is not indicated at this time the patient is not experiencing cardiac or respiratory failure. Think priority and the first step in assessment observation. The nurse considers information regarding smoking cigarettes and marijuana essential for pregnant women because it is well established that these activities may lead to: Retarded infants. Low-birth-weight infants. Deformed infants. Malnourished infants. The one factor that has been highly correlated to smoking cigarettes and marijuana is low birth weight. Answers 1, 3, and 4 are incorrect because retardation, deformation, and malnourishment do not have a high correlation to smoking cigarettes and marijuana. Think low birth weight = high risk (i.e., high correlation). Choose the least serious consequence as the highest probability for causing the condition. Review teratogenic and high-risk substances women may use during pregnancy. Know the most common effects of these substances on the fetus/newborn. The nurse finds a post-MI patient slumped on the side rails of the bed. The patient does not respond when the nurse shakes the patient's shoulders and loudly calls the patient's name. The nurse's next action is to: Call for help and note the time. Clear the airway. Give two sharp thumps to the precordium. Administer two quick breaths. Having established, by stimulating the patient, that he or she is unconscious rather than asleep, the nurse should immediately call for help. This may be done by dialing the operator from the patient's phone and giving the hospital code for cardiac arrest and the patient's room number to the operator, or if a phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure. Answer 2 is incorrect because clearing the airway follows an unsuccessful attempt to ventilate. Answer 3 is incorrect because checking the pulse follows after the airway has been established and ventilation has begun. Answer 4 is incorrect because initial ventilation includes two full breaths. Remember the sequence for CPR "help," then ABC? Postoperative orders include "IV of D5 1/4 NS at 75 mL per hour." At 7:00 p.m., a new 1000 mL bag of fluid is hung. If the IV infuses at the prescribed rate, how much fluid should be left in the bag at 7:00 a.m.? 100 mL. 900 mL. Nothing should be left; bag should be empty. Not enough information is given to determine this. If the IV infuses at the prescribed rate of 75 mL per hour from 7:00 p.m. to 7:00 a.m., or 12 hours, 75 mL X 12 hours = 900 mL infused. If a 1000 mL bag were hung and 900 mL infused, 1000 - 900 = 100 mL left in the bag. Answers 2 and 3 are incorrect calculations. Answer 4 is incorrect because there is enough information to determine this. Looks more difficult than it is. Just multiply and subtract. As a cardiac patient gets up to use the commode, he turns ashen and diaphoretic. Vital signs are as follows: BP 128/60, pulse 42, respirations 24. ECG shows patterns of complete heart block. The nurse knows that the patient's signs and symptoms are related to: Inability of heart to increase its rate during exertion. Insufficient blood flow to the coronary arteries. Increased stroke volume. Inability of the circulatory reflexes to increase venous return. The inherent rate of ventricular excitable tissue is between 20 and 40 and does not increase significantly with exertion in complete heart block. Answers 2 and 3 are incorrect because this phenomenon results in decreased cardiac output despite increased diastolic filling time, coronary artery blood flow, and stroke volume with each ventricular contraction. Answer 4 is incorrect because the decreased cardiac output results in stimulation of circulatory reflexes to increase venous return, which produces peripheral vasoconstriction, the cause of the patient's pallor and diaphoresis. Look for a similar idea in answer. A woman is in labor; she and the father learn that the fetus is in the transverse position. The father tells the nurse that they had counted on his being with her throughout their baby's birth. The nurse's most therapeutic response would be to: Refer him to the attending physician for permission to attend the birth. Ask if he has attended childbirth education classes. Check with the attending physician and relay the response to the couple. Tell the father to dress and meet the nurse in the cesarean room. Depending on the hospital, this is a physician's decision, especially in cases where the fetus, as well as the mother, maybe in danger. Answer 1 is incorrect because time may not permit a physician referral to occur. Answer 2 is incorrect because although some hospitals and/or physicians require childbirth classes as a prerequisite to attending the birth, others do not require it. Answer 4 is incorrect because it is an inappropriate nursing action without a physician's approval. This is the MD's decision, but the nurse's role is to act as an advocate by going to the MD. Parents of an infant on an apnea monitor ask the nurse what the monitor will do. The nurse's most appropriate response would be: It will stimulate your baby's breathing. It will monitor your baby's vital signs. It will sound an alarm if your baby's breathing stops. It will maintain your baby's respirations. The apnea monitor will sound an alarm during any periods of apnea to warn the parents or caretakers. Answer 1 is incorrect. Although the alarm may startle the infant and stimulate breathing, it should not be relied on for this function. Answer 2 is incorrect because the monitor screen displays the infant's respirations (and pulse, with some monitors) but not temperature. Answer 4 is incorrect because the monitor will not maintain the infant's respirations. Review the function of an apnea monitor and narrow the choice to an option that has "breathing" and "alarm" (what a monitor does)? Preoperative teaching includes deep breathing and coughing. What is the least desired outcome of the teaching plan? The patient: States the rationale for repeating these exercises every 1-2 hours postoperatively. Demonstrates coughing technique. Inhales through both nose and mouth and raises abdomen with each respiration. States she recognizes the need to repeat exercises until she is feeling light-headed. To repeat the breathing exercises until the patient is light-headed is inappropriate. It indicates hyperventilation, which may lead to tetany due to loss of volatile hydrogen ions. Patients should, however, be able to supply a rationale for deep breathing and coughing techniques (Answer 1), as well as demonstrate them correctly (Answer 2). Answer 3 is also a desirable outcome. Least desired outcome will be low priority. A patient's blood gases are as follows: Po2 85, Pco2 37, pH 7.35, HCO, 19. The nurse's analysis of this patient's blood gases indicate: Compensated metabolic acidosis. Hyperventilation. Uncompensated metabolic acidosis. Alveolar hypoventilation. The patient's pH is within normal range (pH 7.35-7.45). Therefore, even though the serum bicarbonate level is reduced, indicating metabolic acidosis, the lungs have been able to excrete enough C02 to keep the total pH within normal range. Answer 2 is incorrect because Pco2 in hyperventilation is reduced (less than 40 mm Hg), but serum bicarbonate levels are usually normal. Answer 3 is incorrect because a pH below 7.35 would represent uncompensated metabolic acidosis. Answer 4 is incorrect because in alveolar hypoventilation the Pco2 is elevated and the condition of respiratory acidosis exists. Know normals and what "compensated" looks like. In doing a child's admission assessment, the nurse should be alert to note which signs/symptoms of chronic lead poisoning? Irritability and seizures. Dehydration and diarrhea. Bradycardia and hypotension. Petechiae and hematuria. Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This results in irritability and changes in level of consciousness, as well as seizure disorders, hyperactivity, and learning disabilities. Answer 2 is incorrect because lead poisoning may affect the GI tract and cause constipation, nut diarrhea. Answer 3 is incorrect because lead poisoning may also cause anemia and tachycardia, not bradycardia. Answer 4 is incorrect because lead poisoning does not cause bleeding tendencies. Think neurological signs and symptoms. A woman is hospitalized with mild preeclampsia. In planning the woman's care during this hospitalization, which nursing order is least likely to be implemented? Vital signs and FHR and rhythm q4h while awake. Daily weight. Deep-tendon reflexes once per shift. Absolute bed rest. Although reducing environmental stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges. Answer 1 is incorrect because her vital signs and fetal heart rate and rhythm should be assessed at least once per shift during the time she is awake. Answer 2 is incorrect because her daily weight is an indicator of her response to treatment and loss of edema. Answer 3 is incorrect because deep-tendon reflexes do assist in assessing the degree of CNS hyperirritability. When a question asks for least likely, choose the response that is not necessary to do. Recall a plan of care for woman with mild preeclampsia vs. severe preeclampsia? The nurse prepares a patient for tracheostomy based on the knowledge that the purpose of a tracheostomy is to: Decrease patient anxiety by increasing the size of the airway. Provide more controlled ventilation and ease removal of secretions the patient is unable to handle. Provide increased cerebral oxygenation, thereby preventing further respiratory depression. Facilitate nursing care, because tracheal tubes have fewer side effects than nasotracheal tubes. The purpose of a tracheostomy is to provide more controlled ventilation and to ease removal of respiratory secretions. When long-term therapy is indicated, it reduces or prevents respiratory fatigue. A tracheostomy is done when intubation is necessary for longer than 3-5 days, when the patient is unable to handle respiratory secretions, or if there is upper-airway obstruction. Answer 1 is incorrect because although anxiety will be decreased when ventilation is improved, this is not the primary purpose for a tracheostomy. Answer 3 is incorrect because desired effects of improving ventilation include improved cerebral oxygenation. Answer 4 is incorrect because a side effect of tracheostomy is increased risk of pulmonary infection, which is not true in the case of endotracheal intubation, though both may cause injury to mucous membranes. Look for the broadest choiceimprove ventilation. A teenager with a history of substance abuse is hospitalized for hallucinatory behavior. The mother is very upset. She is in the waiting room crying uncontrollably. The most appropriate nursing action would be to: Provide privacy for her. Ask the physician to order diazepam (Valium) for her. Contact her husband. Offer to sit with her. Acknowledging her presence and discomfort is most important to provide emotional support. Answer 1 is incorrect: privacy is important if she requests it; however, assuming that she wants to be isolated may cause feelings of rejection and loneliness. Answer 2 is incorrect because an assessment of her overall level of functioning and coping abilities must be performed before any medication is prescribed. It is also the doctor's decision to give medication. Answer 3 is incorrect: such a decision must be discussed with her. Most appropriate action is to provide emotional support? The pressure dressing placed after modified mastectomy encircles the patient's chest and fits very snugly. The nurse should anticipate difficulty in which postoperative nursing function? Maintaining good body alignment. Initiating arm exercises. Promoting deep breathing and coughing. Taking vital signs. Tight pressure dressing, discomfort, and fear of tearing the incision tend to limit chest expansion and the patient's willingness to cough. The nurse can assist the patient in this procedure by helping her sit upright and by supporting (with her hand) both the anterior and the posterior chest wall at the incisional site. Frequent turning will also facilitate mobilization of secretions and the prevention of atelectasis. Answer 1 is incorrect because the dressing is on the chest wall and will not interfere with body alignment. Answer 2 is incorrect because arm exercises initially will be isometric and can be done with the dressing in place. Answer 4 is incorrect because vital signs should be checked on the inoperative arm. Visualize the patient (chest constricted). The nurse must be on the alert constantly for anaphylaxis, an immediate hypersensitivity reaction, characterized by local reactions such as: Angioedema. Cardiovascular collapse. Nausea, vomiting, diarrhea. Asthma-like symptoms. A local hypersensitivity reaction is angioedema, redness and swelling. Answer 2 is incorrect because cardiovascular collapse is a systemic reaction. Answer 3 is incorrect because nausea with vomiting and diarrhea represents a systemic reaction. Answer 4 is incorrect because asthma-like symptoms also represent a systemic reaction. Key word is local. Three choices involve major systems. If the first day of a pregnant woman's last menstrual period (LMP) was July 10, what is her baby's expected date of birth (EDB)? April 17. May 30. March 14. June 1. According to Nagele's rule (LMP - 3 months + 7 days), the calculations would be: 7/10 3 months = 4/10 + 7 days = 4/17. Nagele's rule assumes that the woman has a 28-day cycle and that pregnancy occurred on the fourteenth day. If the woman's cycle is longer or shorter than 28 days, appropriate adjustments must be made. Only about 4-5% of women give birth on the EDB plus or minus 7 days. Answers 2, 3, and 4 are incorrect calculations. Use Nagele's rale. A simple method is to count +9 months from the LMP, + 7 days?. At 7:00 A.M., the night nurse hangs a new 500 mL bag of D5 1/2 NS and adjusts the flow rate to 35 mL/hr per MD order. If the IV infuses at the proper rate, how much fluid should be left in the bag when the day nurse makes rounds at 11:30 a.m., halfway through the shift? 160 mL. 250 mL. 340 mL. Unable to determine. If the IV infusion was at the prescribed rate of 35 mL/hr for 4.5 hours, from 7:00 a.m. to 11:30 a.m., 35 mL X 4.5 hours = 157.5 mL absorbed. If 500 mL was hung at 7:00 a.m., and approximately 160 mL was infused, 500 160 = 340 mL left in the bag at 11:30 a.m. Answers 1 and 2 are incorrect calculations. Answer 4 is incorrect. Use basic math, not a formula. An adolescent patient with a history of substance abuse asks the nurse, "Have you ever used drugs?" The most appropriate nursing response would be: Yes, once I tried grass. Why do you want to know? How will my answer help you? No, I don't think so. The patient may perceive this as avoidance, but it is more important to redirect back to the patient, especially in light of the manipulative behaviors of drug abusers and adolescents. Answers 1 and 4 are incorrect because they provide information about the nurse's personal life that is irrelevant to the maintenance of a therapeutic relationship. Answer 2 is incorrect because it plays into the patient's manipulation. Review therapeutic communication. This is a technique to redirect focus back to the patient. Answers 1 and 4 focus on the nurse? A woman is in labor; her membranes are ruptured by the attending physician. The nurse should expect the amniotic fluid to: Be slightly bloody. Have a slightly pungent odor. Have a thick consistency. Turn litmus paper blue. Amniotic fluid is alkaline, which makes litmus paper turn blue. Answer 1 is incorrect because the fluid is usually milky or opaque with small white flecks (vernix caseosa), not bloody. Bloody amniotic fluid may indicate abruptio placentae. Answer 2 is incorrect because no offensive odor is usually apparent. Answer 3 is incorrect because most amniotic fluid has a thin consistency, not thick. Think amniotic = alkaline (blue litmus). The nurse should know that the majority of amputations are attributed to: Chemical burns. Diabetic ulcers. Arteriosclerosis obliterans. Bone tumors. Although some complete or partial amputations may result from trauma (Answer 1), the majority are necessitated by arteriosclerosis obliterans. Answer 2 is incorrect because long-standing complications of diabetes mellitus are peripheral vascular insufficiency and infections, which in turn may increase the likelihood of amputation. Answer 4 is incorrect because bone tumors, particularly of the knee, necessitate amputation less often than arteriosclerosis obliterans. Think broad and most encompassing?. A 15-year-old is admitted to the hospital with a compound fracture of the left tibia and patella following a minibike accident. The fractures are repaired surgically, and a long leg cast is applied. During the first night in the hospital, the patient complains of severe pain in the left leg. At this time, it would be most appropriate for the nurse to: Obtain more information about the characteristics of the pain. Give the patient a dose of "Demerol 50 mg IM prn q4-6h" as ordered. Reassure the patient that the pain will diminish in a few days. Distract the patient by turning on the television. Initially, the nurse must obtain more information about the patient's pain before giving medication. Answer 2 is incorrect because if the pain were due to compression of the leg by a cast that is too tight, medicating the patient could result in serious neurovascular complications. Answers 3 and 4 are incorrect because offering reassurance or distraction is not appropriate at this time, or a sufficient nursing intervention. Assessment is always the first step of the nursing process? When caring for a child who has received a diazepam (Valium) "IV push" X 2 during a procedure, which vital sign should the nurse evaluate first? Temperature. Pulse. Respirations. Blood pressure. Diazepam is a CNS depressant, and in children and elderly adults, it may depress the respiratory center. Thus, when the patient returns to the unit, the nurse should first evaluate respirations. Answers 1, 2, and 4 are incorrect. After determining that the patient is breathing adequately, the nurse can then evaluate the temperature, pulse, and blood pressure. Patent airway and respirations are always the priority of care. Several weeks after the funeral of one of her twin infants, a mother tells the community health nurse that she is experiencing difficulty producing enough breast milk to satisfy the other infant. The most appropriate response for the nurse to make would be: You probably have a virus and should see a doctor right away. Your baby is probably reacting to the loss of a sibling and not sucking long enough to stimulate an adequate supply. Milk production may decrease with an increase in stress. The lactation ducts may be occluded. Many times the physiological response to stress may be a decrease in milk production. This may rectify itself over time, provided the anxiety is controlled. However, as long as the system is under prolonged, intense stress, the milk supply will probably remain diminished. Answers 1 and 4 are incorrect because the nurse does not have physiological evidence to substantiate the probability of a virus or of occluded lactation ducts. Answer 2 is incorrect because the surviving infant is probably too young to react physiologically to the twin's death. However, it is possible that the infant is experiencing some emotional trauma in response both to the increase in familial tension and to not hearing or seeing the other twin. Think funeral = increased stress. Note the similarity between the stem ("producing... milk") and Answer 3 ("milk producing"). Review factors that might alter normal lactation? When parents ask how their baby might have gotten pyloric stenosis, the nurse should tell them that: Their baby was born with this condition. Their baby acquired it due to a formula allergy. Their baby developed this condition during the first few weeks of life. There is no way to determine this preoperatively. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops gradually during the first few weeks of life. Answer 1 is incorrect because pyloric stenosis is not present at birth. Answer 2 is incorrect because pyloric stenosis is not acquired due to a formula allergy. Answer 4 is incorrect because the presence of pyloric stenosis is well known before surgery. Know the facts about causation in order to answer correctly? Morphine sulfate, 0.6 mg, has been ordered to relieve the chest pain of a patient who has had an anterior MI. The nurse would give this narcotic to: Increase the threshold for pain tolerance and decrease arterial resistance. Increase arterial resistance and reduce apprehension and anxiety, as well as pain. Relieve apprehension, anxiety, and pain and stimulate medullary respiratory centers. Reduce venous capacitance and reduce pain threshold. Morphine sulfate acts on subcortical brain levels not only to inhibit perception of pain and to decrease apprehension and anxiety by inducing euphoria, but also to decrease sympathetic nervous system stimulation, thereby reducing peripheral arterial resistance and increasing venous capacitance. A side effect of this last action is hypotension. Answer 2 is incorrect because morphine reduces arterial resistance. Answer 3 is incorrect because a second side effect of morphine is respiratory depression. Answer 4 is incorrect because it describes actions directly opposite to the effects of morphine. Know expected effect of morphine on blood vessels. A pregnant woman with severe preeclampsia is at 38 weeks of gestation; she is in active labor, with contractions every 10 minutes, and her membranes ruptured 45 minutes ago. Her husband is with her. The nurse's primary intervention would be to: Teach the couple about the stages of labor. Prepare the woman for birth. Assess the couple's degree of preparation. Answer any questions the couple may have. In this case the nurse's calm, assured manner would be most therapeutic. It would serve to decrease the couple's anxiety and to facilitate an effective admission, labor, and birth. Answer 1 is incorrect because the couple's anxiety level would probably interfere with effective learning at this time. However, reinforcing any previously learned material and answering questions may be used. Answer 2 is incorrect because although the woman is in active labor, she is not ready to give birth at this time. Answer 3 is incorrect because assessing the couple's level of preparation would be done in conjunction with answering questions. It would be more important to assess their level of readiness rather than preparation at this time. When two answers are correct, select the one that encompasses them both (in this case, by answering whatever questions they have, the nurse will be able to assess their level of preparation)? In preparing preop injections for a 3-year-old, which size needle would the nurse be most correct in selecting to administer the IM injection? 25G,5/8inch. 21 G, 1 inch. 18 G, 1 inch. 18 G, r/2inch. In selecting the correct needle to administer an IM injection to a preschool child, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the "average" preschool child. A medium-gauge needle (21 G) that is 1 inch long would be most appropriate. Answer 1 is incorrect because a 5/s inch needle would be too short. A 25 G needle would be too thin to use on most preschool children. Answer 3 is incorrect because an 18 G needle would be too large (wide) to use on most preschool children and would be better suited for a school-age child or an adolescent. Answer 4 is incorrect because a 1 1/2 inch needle would be too long. An 18 G needle would also be too large (wide) to use on most preschool children and would be better suited for a school-age child or an adolescent. Select the midpoint: not too long, not too short; not too narrow, not too wide? The physician orders the insertion of a permanent pacemaker for a patient with complete heart block. In preparing a preoperative teaching plan for this patient, the nurse would initially: Assess the patient's interest in learning about the procedure and current understanding. Invite the patient's family to join the preoperative teaching session. Ascertain from the physician the amount of information she or he has given the patient. Have the operative permit signed, then institute the teaching plan. Before beginning any teaching plan, the nurse must assess the patient's current understanding of the procedure, as well as his or her interest and ability to comprehend different facets of it. The physician has generally given the patient an outline of the facts as to why the procedure is necessary. Answer 2 is incorrect because the patient's husband, wife, or significant others may be invited to join the teaching session if the clinical situation allows; otherwise they should be informed separately. Answer 3 is incorrect because several intervening variables, such as anxiety and decreased cerebral perfusion, may be affecting the patient's ability to absorb information. Therefore, it is frequently necessary not only to reinforce information given by the physician but also to re-explain the procedure. Answer 4 is incorrect because after explanations of the procedure, the operative permit is signed, thereby ensuring informed consent. Think priority. What should be done before teaching? Following administration of preoperative medication, it is important for the nurse to: Position the patient in high Fowler's position to improve ventilation. Let the patient know that the patient will be asleep when the nurse leaves the unit. Tell the patient that a nurse will be there when the patient returns. Get the patient up to the bathroom when he or she complains of bladder fullness. When the patient knows what to expect or who will do the care on return from the operating room, anxiety decreases. Answer 1 is incorrect because it would be difficult for the patient to relax in high Fowler's position, and at this time there is no documented evidence of respiratory distress. Answer 2 is incorrect because the patient may be drowsy but may not be asleep. Assuring the patient that he or she will be asleep gives false information. Answer 4 is incorrect because the patient should void before medication is given, not after. Look for safety and security? In the first few hours after cardiac catheterization, which nursing measure would be most essential? Checking pedal pulse in the extremity used for the cut-down. Encouraging the patient to cough and deep breathe hourly. Keeping the patient sedated to maintain the pressure dressing. Monitoring the patient's urine output. When cardiac catheterization is performed, a countdown must be performed on a major artery in either an arm or a leg; thus, essential nursing care following this procedure involves checking the pulse in the affected extremity to be sure there is adequate circulation. Answer 2 is incorrect because following cardiac catheterization, during which the patient does not receive anesthesia, deep breathing is unnecessary and coughing is contraindicated, as it may cause hemorrhage at the cutdown site. Answer 3 is incorrect because there is no need to sedate the patient following this procedure, although bed rest for several hours is usually recommended. Answer 4 is incorrect because in general, cardiac catheterization should have little or no effect on urine output; therefore, there would be no specific need to monitor urine output. When there is more than one correct answer, determine which is most important to the patient immediately. The nurse has established the unresponsiveness of a patient. After the airway is opened, the next nursing action would be to: Look, listen, and feel for breathing. Pinch the patient's nostrils and give two full breaths. Check the patient's carotid pulse for 5-10 seconds. Finger sweep the patient's mouth for any foreign object. After opening the airway by head tilt and chin lift, the nurse must look, listen, and feel for any movement of air. Often opening the airway may be all that is needed. Giving two breaths (Answer 2) is done after establishing breathlessness, followed by checking the pulse (Answer 3). Finger sweeps (Answer 4) are only done if ventilation is unsuccessful and back blows have been done. Remember the ABCs of CPR? While the nurse is changing a CVP dressing, the patient becomes tachypneic and complains of chest pain. The nurse suspects the symptoms are related to an air embolism. The first nursing priority would be to position the patient: In Trendelenburg. On the left side, head down. On the right side, head up. Supine, in high Fowler's. The nurse should quickly turn the patient onto the left side, lowering the head of the bed to minimize the chance of air bubbles entering the cerebral circulation, and notify the physician. Answer 1 is incorrect because, alone, Trendelenburg is insufficient; the air must be trapped in the right ventricle (left-side position). Answer 3 is incorrect because turning the patient to the right side, head up, would facilitate movement of the air embolism through the circulation and potentially to the brain. Answer 4 is incorrect because supine in high Fowler's position would facilitate movement of the air embolism through the circulation and potentially to the brain. Visualize where the air is in the heart and keep it there? A pregnant woman is in active labor and has not received any anesthesia. She is in the transitional phase of the first stage of labor. During this time the nurse would expect her to be: Irritable. Excited. Euphoric. Serious. The woman is more apt to become irritable, uncooperative, and discouraged during the transitional phase. Answers 2 and 3 are incorrect because excitement and euphoria are associated with the latent phase, not the transitional phase. Answer 4 is incorrect because seriousness is associated with the active phase, not the transitional phase. The key element is when (i.e., timing). Match the stage (active labor, latent phase, transitional phase) with the corresponding expected emotional reaction. An adolescent patient's girlfriend comes to visit him in the hospital. The nurse suspects that they may become intimate. What is the most appropriate nursing intervention? Do not allow his girlfriend to visit. Inform the couple that "necking" is prohibited. Provide privacy from staff and other clients. Allow visitation with supervision. Although the nurse suspects that this behavior may occur, there is no valid concern unless the couple's behavior becomes inappropriate. The nurse needs to realize that kissing is a normal part of adolescence. Answer 1 is incorrect because some privacy may be provided; however, periodic supervision is warranted because the patient is an adolescent. However, the patient still needs companionship. Answer 2 is incorrect because he needs to feel trusted in order to develop into an independent and mature person. Answer 2 also serves only to highlight mistrust, and the couple may already feel that intimacy is inappropriate in this setting. Answer 3 is incorrect because privacy is needed, but with some supervision to promote responsible behavior. Choose "allow" rather than "do not allow" and "prohibit.? A patient is to be discharged on a 2 g sodium diet. The nurse would know that the patient understands the dietary limitations if he or she selected: Filet of sole, tossed salad with lemon juice, coffee. Chow mein, fried rice, tea. Canned tomato soup, unsalted crackers, skim milk. Two hot dogs with mustard, macaroni salad, ginger ale. Fresh fish with scales would be permitted on a mildly restricted (2 g) to an extremely restricted (200 mg) sodium diet. Only shellfish are restricted. Answers 2, 3, and 4 are incorrect because foods to be avoided on a sodium-restricted diet include ethnic foods, particularly Chinese, which is usually prepared with soy sauce; commercially prepared soups, such as canned tomato soup; and hot dogs, which are a commercially prepared meat. Look for similarities in answers. Only one choice is fresh cooked. A patient complains of increasing shortness of breath with exercise. On physical examination, the patient is found to be moderately overweight and has BP 152/105, pulse 81, respirations 16, and fine basilar crackles in both lung fields, and the point of maximal impulse (PMI) is shifted to the left and down by 1.5 cm. The best explanation the nurse could offer this patient is that this shortness of breath is most likely related to: Inadequate functioning of the left ventricle. Insufficient blood return to the right side of the heart. Asynergistic pumping of the left ventricle. Obesity and sedentary lifestyle. During exercise there is a general increase in vasomotor tone, which increases venous return. To meet the increased metabolic needs of the body, the heart normally increases its rate and stroke volume. In this patient's case, left ventricular hypertrophy has compromised the heart's ability to increase its efficiency during exercise. Therefore, even though the heart rate is increased, the stroke volume does not increase sufficiently, so the increased venous return tends to back up into the pulmonary vasculature. This results in the perception of increased work of breathing, or shortness of breath. Answer 2 is incorrect because venous return is increased with exercise. Answer 3 is incorrect because asynergistic cardiac contractions occur when a portion of the heart is noncontractile, as with myocardial infarction with ventricular aneurysm. Answer 4 is not correct because obesity and sedentary lifestyle are contributing factors to physiological phenomena underlying the symptoms. Visualize blood flow through the heart and lungs. Breathing problems will occur if... The best approach for the nurse to take in administering a preop injection to a preschooler would be to: Ask the mother to explain the injection to the child. Simply give the injection as quickly as possible without telling the child anything, because it may scare the child. Give a short and simple explanation immediately before giving the injection. Tell the child the injection must be given and then the mother can read a story. The best approach in administering an injection to a preschooler is to give a short, simple explanation immediately before giving the injection, being truthful that it will hurt. This helps maintain the child's sense of trust in the nurse. Answer 1 is incorrect because the nurse should not rely on the mother to give an appropriate explanation. Answer 2 is incorrect because the nurse should not give the injection without telling the child anything. Answer 4 is incorrect because the nurse should not attempt to bribe the child. Use the process of elimination to omit "mother" (the question asks for a nursing action) and "must" (too mandatory). Then focus on "tell" vs. "not tell.? The nurse explains that the primary objective of a preoperative skin prep is: To clean the skin of excess oils and hair. To prevent postoperative infection by sterilizing the skin. To prevent postoperative infection by reducing the number of microorganisms on the skin. To provide a clear field for the incision. Skin preps are designed primarily to reduce the occurrence of postoperative infections by reducing the number of microorganisms on the skin and by removing any hair that may tend to harbor these organisms. Answer 1 is incorrect because cleaning excess oils and hairs is a secondary objective of a skin prep. Answer 2 is incorrect because skin preps do not sterilize the skin or kill all the microorganisms. Answer 4 is incorrect because providing a clear field is a secondary objective of a skin prep. Look for the broadest and most important choice. Because a patient who hallucinates is not in touch with reality, the most appropriate nursing intervention would be to: Maintain a safe environment. Establish a trusting relationship. Orient the patient to time, place, and person. Isolate the patient from other patients. It is of paramount importance to prevent the patient from hurting himself or herself or others. Answer 2 is incorrect; the nurse cannot establish a trusting relationship at this time because the patient is unable to communicate effectively. Answer 3 is incorrect because the patient cannot be oriented to time, place, and person until he or she is able to communicate. Answer 4 is incorrect because to isolate the patient is only one aspect of maintaining a safe environment, which will prevent the patient from harming others, as well as protect the patient from overstimulation. Safety is a most appropriate intervention. Which hobby will most likely be restricted for an adult following recovery from pacemaker insertion? Swimming. Fashioning lamps from driftwood and metal. Operating ham radio. Playing golf. Patients with permanent pacemakers are cautioned to avoid all sources of high electronic output because they may cause pacemaker malfunction. Other sources of high electronic output include older, noninsulated microwave ovens, running car engines, and dental drills. Answers 1 and 4 are incorrect because activities such as swimming and golf can be resumed usually after 5 weeks. Answer 2 is incorrect because creative hobbies such as fashioning lamps are indicated as long as precautions are taken to avoid electrical shocks. Look for a restricted or potentially "risky" activity. During the first 24-48 hours after admission, the most appropriate diet for a patient who has GI bleeding is likely to be: NPO. Clear liquids. A soft, bland diet. Skim or regular milk. The patient is kept NPO until shock and bleeding are controlled. Often a nasogastric tube is inserted to drain off blood and to provide a route for antacid therapy. Answer 2 is incorrect because a liquid diet is started after shock and bleeding have been controlled. Answer 3 is incorrect because a soft, bland diet is started after a liquid diet has begun. Answer 4 is incorrect because milk is not given; it increases gastric acid production. This is a priority question-what is safest for the patient at this time? If a woman is pregnant for the second time, but her first pregnancy did not reach viability, what would be her parity using the four-digit scoring system? 1-0-0-1. 0-0-1-0. 0-1-0-0. 0-1-0-1. The "formula" for determining parity is TPAL: T is the number of term pregnancies (38 + weeks); P is the number of preterm pregnancies (20-37 weeks); A is the number of abortions (pregnancies that do not reach viability, 20-22 weeks of gestation); L is the number of living children. This woman's first pregnancy ended in abortion and she has no living children. Her parity is T = 0, P = 0, A = 1, L = 0; or 0-0-1-0. Answers 1, 3, and 4 are not correct according to this formula. Use the TPAL system: term, preterm, abortions, living children. After determining that a patient is pulseless, the nurse would begin adult one-person CPR at a minimum compression rate of: 60 compressions per minute. 80 compressions per minute. 90 compressions per minute. 100 compressions per minute. One-person or two-person CPR for adults is done at a minimum rate of 80 compressions per minute (up to a rate of 100). Sixty compressions per minute (Answer 1) is no longer considered adequate in CPR. Answers 3 and 4 are both within the range of acceptable rates; however, the ques tion asks for the minimum rate. Asks for minimum rate (know 80). A patient has had an appendectomy, following a ruptured appendix. During postop care, the nurses' notes in this patient's chart should include documentation of: Teaching to prevent dumping syndrome and to promote early ambulation. Frequent mouth care and dressing changes, including drainage. Bowel sounds, intake and output, and the need for a low-residue diet. Dressing changes, intake and output, and bowel sounds. Following an appendectomy, the nurses' notes in the patient's chart should include the dressing changes, input and output, and return of bowel sounds. Answer 1 is incorrect because dumping syndrome is not a common complication following an appendectomy. Answer 2 is incorrect: mouth care and dressing changes should be noted but are not as critical as charting input and output and bowel sounds. Answer 3 is incorrect: following a ruptured appendectomy, a patient will be NPO initially and then gradually advanced; a low-residue diet is not routine. Potentially life-threatening situation think priority nursing assessment. Three hours after admission to the CCU for anterior myocardial infarction (MI), a patient develops increasing ventricular ectopy, followed by a short burst of ventricular tachycardia. The first nursing action is to: Notify the attending physician. Increase the flow of O2 from 4 to 8 liters. Administer a bolus of lidocaine, per order. Repeat the morphine sulfate, per order. Lidocaine is the treatment of choice in this situation. Ventricular tachycardia is a serious arrhythmia. It must be treated at once because (a) it may compromise cardiac out put and (b) it is considered a precursor of ventricular fibrillation. Answer 1 is incorrect because standing coronary care unit orders generally cover the administration of lidocaine in this situation, so it is not necessary to notify the physician to obtain a verbal order. Answer 2 is incorrect because O2 flow rate is increased only if clinical signs indicate the patient is in distress, which is unlikely with a short burst of ventricular tachycardia. Answer 4 is incorrect because research data indicate that morphine sulfate may stabilize the threshold for ventricular fibrillation, but it is not the drug of choice in this situation. Life-threatening situation requires direct (drug) action? Sudden infant death syndrome (SIDS) occurs most frequently with which risk factor? Hispanic. Low birth weight. Midrange socioeconomic status. Breastfeeding. SIDS occurs most frequently in low-birth-weight, preterm infants, and in the lower, not middle (Answer 3), socioeconomic groups. Answer 1 is incorrect because SIDS occurs most frequently in blacks and Native Americans, not Hispanics. Answer 4 is incorrect because SIDS has a lower incidence in breastfed infants. -Review risk factors; when in doubt, choose an objective risk factor. After a patient returns from surgery following craniotomy, the nurse knows that the optimum positioning of a neurosurgery patient, unless otherwise indicated, would be: Flat on back. Head elevated 30 degrees. Head elevated 45 degrees. Head elevated 90 degrees. Elevation of 20 30 degrees is the optimum position to reduce intracranial pressure, aid venous drainage from the brain, and facilitate respiration. Answer 1 is incorrect because flat on the back may increase the chance of aspiration. A lateral or semiprone position may be indicated in the early postoperative period if there are no signs of cerebral edema. Answers 3 and 4 are incorrect because they may increase the amount of hip flexion and can contribute to an increase in intracranial pressure. Picture the patient position. Optimum is key to head and limb positioning. Immediately before a woman is to give birth, her husband expresses anxiety about staying with her. The most appropriate response the nurse could make would be: Many people feel frightened at this time. You'll do fine, don't worry. Think of your wife. How will she feel if you don't stay? Once things get going, you'll forget about being afraid. Providing reassurance that it is normal for most people to fear the unknown may bolster the husband's confidence. If more time were available, the nurse would try to explore his fears and provide emotional support. Answer 2 is inappropriate because it provides false reassurance, which may merely increase his anxiety. Answer 3 is incorrect because it may stimulate feelings of guilt. Answer 4 is incorrect because it may not necessarily be true and may provide false reassurance. Eliminate the cliches and false reassurances, and select the option that acknowledges feelings. Which type of anesthesia should the nurse anticipate will be used for an amputation? IV regional. Spinal. General intravenous and inhalation anesthesia. Muscle relaxant. The choice of anesthesia depends on the surgeon's choice and the patient's condition. Answer 1 is incorrect because IV regional blocks may not provide adequate blockage of impulses for this procedure, and the patient would be awake. Answer 2 is incorrect: though a spinal anesthetic may be used, the sawing of the bone can be very distressing to the patient, so usually a general anesthetic is preferred. Answer 4 is incorrect because muscle relaxants are administered in conjunction with general anesthesia. Look for an ideal choice. To facilitate the proper drying of a long leg cast, the nurse should include which measure in the plan of care? Leave the cast exposed to the air. Encourage the patient to remain in one position. Place the patient on a bedboard. Use only tips of the fingers to handle the cast. The cast should be fully exposed to the air to help it dry properly. Answer 2 is incorrect because the patient should be turned every 2 hours to help the cast to dry, not remain in one position. Answer 3 is incorrect because the cast should be elevated and placed on pillows rather than a bedboard. Answer 4 is incorrect because the cast should be handled with the palms of the hands to avoid pressure and making indentations with the fingers. Consider patient comfort and proper technique. Which nursing care procedure is least important during the period before insertion of the pacemaker? Providing sedation to relieve anxiety and promote relaxation as needed. Instituting arm and leg range of motion exercises to prevent postinsertion complications. Establishing an intravenous line and having emergency equipment and medications available. Weighing the patient and instituting intake and output records. Weighing the patient and instituting intake and output records are admission procedures; therefore, they are the least important. Answer 1 is incorrect: providing sedation to relieve anxiety and promote relaxation is a greater priority than weighing the patient and instituting records. Answer 2 is incorrect: instituting arm and leg range-of-motion exercises is a greater priority than weighing and instituting records. Answer 3 is incorrect: establishing an intravenous line is a greater priority than weighing the patient and instituting records. Look for lowest priority at the time. On turning a patient who has had a right modified mastectomy to her left side, the nurse notes a moderately large amount of serosanguineous drainage on the bed sheets. The nurse should: Remove the dressing to ascertain the origin of the bleeding. Milk the Hemovac tubing, using a downward motion. Note vital signs, reinforce the dressing, and notify the surgeon immediately. Recognize that this is a frequent occurrence with this type of surgery. Pressure dressings are never removed (Answer 1), but if saturated, they should be reinforced with sterile dressings. The possibility of hemorrhage is ever-present, and signs of increased bleeding should be immediately reported to the surgeon. This is not a normal occurrence. Vital signs and Hemovac drainage and function should also be assessed. Answer 2 is incorrect: Hemovacs may be irrigated, but generally they are not milked. Answer 4 is incorrect because this is not a normal occurrence. Gather data to interpret finding. Assess. Immediately following birth, an infant's condition is assessed. The respirations do not establish readily, there is slight cyanosis, and there is some muscle flaccidity. The most appropriate nursing action would be to: Initiate CPR immediately. Clear airway and administer oxygen. Reassure the parents. Check the mother's chart for her last medication (drug, time, and amount). Providing and maintaining a patent airway and administering oxygen immediately are essential to establish regular respirations. Answer 1 is incorrect because CPR may not be necessary if respirations are adequately established. Answer 3 is incorrect because reassuring the parents is not appropriate now. No one can accurately predict the outcome at this point. Answer 4 is incorrect because checking the mother's chart for type of drug, amount, and time given is more appropriately the job of a second staff member in attendance. The neonate may be a candidate for naloxone HC1 (Narcan). Think ABCs patent airway. Which nursing action is essential to prevent hypoxemia during tracheal suctioning? Removing oral and nasal secretions. Encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions. Administering 100% oxygen to reduce the effects of airway obstruction during suctioning. Auscultating the lungs to determine the baseline data to assess the effectiveness of suctioning. Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia, which occurs when the flow of gases in the airway is obstructed by the suctioning catheter. Answer 1 is incorrect because it describes the nursing action while suctioning the patient with an endotracheal tube rather than a tracheal tube. Answer 2 is incorrect because it is a proper nursing action before suctioning the patient with an endotracheal tube, not a tracheal tube. Answer 4 is incorrect; although it is a correct nursing procedure before suctioning any patient, it does not prevent hypoxemia. Look for key words in the stem. Prevent hypoxemia - give O2. An expectant couple is informed that a cesarean will be performed immediately. The couple inquires whether the mother must be put to sleep. The most appropriate nursing response would be to: Refer the couple to the anesthesiologist. Ask the attending physician to explain the procedure to the couple. Tell the couple that she probably will receive general anesthesia. Inform the couple that most women who have a cesarean birth receive spinal anesthesia. This response allows the couple to become informed without infringing on the physician's role. The physician can then decide either to inform the couple of the procedures to be used or to have the anesthesiologist inform them. Answer 1 is incorrect because time is limited and the physician may decide to inform the couple himself or herself. Answers 3 and 4 are incorrect because it is not the nurse's role to discuss anesthesia of choice. Choose the appropriate nursing role rather than the MD's role when it deals with explaining emergency procedures. A client is hospitalized for substance abuse and hallucinatory behavior. During the admission procedure, in assessing this client's mother, the nurse would expect her initial reaction to be: Anger. Denial. Acceptance. Shock. In addition to the shock of the immediate crisis, the mother probably has never accepted the fact that her son was extensively involved with drugs. Answer 1 is incorrect because it will take time to develop as she takes in the implications of the situation. Answer 2 is incorrect because this is part of the shock process. Answer 3 is incorrect because acceptance is unrealistic at this time. When two or more options may be correct, choose the broad, more inclusive option (shock instead of denial). What should the nurse see in the vomitus that is characteristic of infants with pyloric stenosis? Stomach contents only. Stomach contents plus bile. Stomach contents streaked with blood. Stomach contents with flecks of feces. In pyloric stenosis, the pyloric sphincter at the distal end of the stomach is thickened, or stenotic. This sphincter blocks the flow of formula into the small intestine, causing vomiting; it also blocks the flow of bile back into the stomach. Thus, the infant with pyloric stenosis characteristically vomits only stomach contents, not bile (Answer 2), blood (Answer 3), or feces (Answer 4). The correct choice is the one that is different ("only"). All of the other choices contain another element (that does not relate to correct anatomy and pathophysiology). At 36 weeks, a pregnant woman's preeclamptic condition changes: she has hyperreflexia, generalized edema, and ataxia. If she begins to have a convulsion, the nurse's primary action should be: Maintain patent ah way. Observe for bowel or bladder evacuation. Administer cardiopulmonary resuscitation. Maintain a safe environment. The primary nursing action would be to maintain a patent airway to ensure oxygen for the woman and fetus. Answer 2 is incorrect because although observing bowel and bladder functioning may also be important for a thorough assessment of the convulsion, it is a lower priority than providing a patent airway or ensuring safety. Answer 3 is incorrect: CPR may be needed if the woman progresses into cardiac arrest; however, in implementing CPR, maintaining a patent airway is again the foremost priority. Answer 4 is incorrect: providing a safe environment is an important second priority. When the question asks for the primary action, choose the action that the nurse would do first and that is the most critical. Remember the ABCs-Airway first. An assessment finding in a patient with an MI that would be an early indicator of the extent of tissue necrosis in the heart is: The duration of sinus tachycardia. CPK and ALT (SCOT) enzyme measures. The duration of chest pain. The occurrence of primary ventricular fibrillation. Although ECG changes can be used to identify the site, extent of changes, and acuteness of an infarct, the extent of the injury is usually approximated by the peak levels of serial enzymes (CPK, ALT [SGOT], LDH). Of these enzymes, CPK-MB or CPK2 gives the most specific information about the amount of myocardial necrosis. Answer 1 is incorrect because sinus tachycardia may result from a number of factors, including emotional responses and heart failure. Answer 3 is incorrect because the duration of chest pain is dependent not only on the extent of tissue ischemia but also on other factors, such as affective responses and muscle spasm. Answer 4 is incorrect because primary ventricular fibrillation does not indicate the extent of infarct; fibrillation occurs due to metabolic changes in the ischemic area. Look for a pattern. Three choices could be ongoing. Correct answer: single point in time (early). Which system should the nurse monitor carefully for possible toxic effects of EDTA? Neurological. Renal. Cardiovascular. Hematological. EDTA and BAL work by binding to the heavy metal lead and promoting its excretion via the kidneys. Renal toxicity may occur as a result. The nurse should force fluids and monitor kidney function carefully. The other choices are incorrect because calcium disodium edetate (EDTA) and dimercaprol (BAL) do not adversely affect the neurological system (Answer 1), the cardiovascular system (Answer 3), or the hematological system (Answer 4). Determine where the drug is excreted; omit neurological, cardiovascular, and hematological systems. The nurse knows that a modified radical mastectomy involves removal of: The breast only. The breast and axillary nodes. The breast, pectoralis major muscle, and axillary lymph nodes. The breast, underlying chest muscle, axillary lymph nodes, and internal mammary lymph nodes. Modified radical mastectomy consists of removal of the breast and all or selected lymph nodes with preservation of the pectoralis major muscle. The other choices are incorrect because they are examples of a simple mastectomy (Answer 1), classic radical mastectomy (Answer 3), and supraradical mastectomy (Answer 4). The key word is modified, something less than radical. An adolescent patient's friend brings a marijuana cigarette. The nurse finds the cigarette under the patient's pillow. The most appropriate nursing action would be to: Ignore the situation. Inform the police. Discuss the incident with the patient's parents. Confront the patient. Being direct with the adolescent about this issue is extremely important because the incident violates hospital policy, the law, treatment, and parents' rules. The patient should be directly confronted and the incident discussed with the patient and the medical staff. The health team will decide whether it is in the patient's best interest to inform the parents and/or the police. Answer 1 is incorrect because avoidance will merely perpetuate the situation. Answers 2 and 3 are incorrect because whether to inform the police or the parents is a health team decision. Two options are opposite actions (ignore vs. confront); eliminate "ignore" because it is a situation where rules are being violated. Eliminate "parent" (3) because the focus should be on the patient. On the first postoperative day following an above-the-knee amputation, a patient's surgeon ordered rehabilitation exercises to begin. Which is most important for the nurse to initiate first! External rotation of the stump. Hyperextension of the thigh and stump. Lifting the buttock and stump off the bed while the patient is lying flat on the back. Arm exercises to prepare for crutch walking. The day following surgery, the patient who has had an above-the-knee (AK) amputation is turned onto his or her abdomen for a short period. Thereafter, he or she is turned to the prone position at least three times daily. While in this position, the patient should practice push-up exercises that strengthen arm and shoulder muscles, thereby facilitating both transfer procedures and preparation for crutch walking. Answer 1 is incorrect; sandbags or blanket rolls are used after this surgery to prevent outward rotation of the stump. Answer 2 is incorrect because hyperextension of the thigh and stump is encouraged for patients with below-the-knee amputations only. Patients with AK amputations may perform this exercise only on medical orders, because it tends to put undue stress on the suture line. Answer 3 is incorrect because the patient is taught at a later time to lift the buttocks and stump off the bed while in a supine position, an exercise that develops abdominal muscles necessary for stabilizing the pelvis when the patient stoops or bends. There is a pattern in three choices (stump); only one strengthens the arms. A toddler is admitted to the hospital with severe eczema lesions on the face, scalp, neck, and arms. The best nursing intervention to prevent the toddler from scratching the affected areas would be to apply: Clove-hitch restraints to the hands. Elbow restraints to the arms. Mittens to the hands. A posey jacket to the torso. The purpose of restraints for this child is to keep the toddler from scratching the affected areas. Mitten restraints would prevent scratching, while allowing the most movement permissible. Answer 1 is incorrect because clove-hitch restraints would needlessly restrict the toddler's movements. Answer 2 is incorrect: elbow restraints are generally inappropriate for children with eczema, because the inner aspect of the arm is usually affected. Answer 4 is incorrect because a Posey jacket would not prevent the child from scratching the affected areas. Choose the least restrictive restraint. During the first stage of labor, maternal and fetal vital signs must be closely monitored. The best time to observe maternal vital signs is: Immediately before a contraction. Between contractions. Immediately after a contraction. Any time the mother feels totally comfortable. Contractions may affect the pulse, BP, and respiratory rate. If possible, take vital signs between contractions. Answer 1 is incorrect because immediately before a contraction the mother is usually very excited and apprehensive. Answer 3 is incorrect because after a contraction she may feel more comfortable, but her vital signs may be altered due to the contraction itself. Answer 4 is incorrect because if the nurse waits for the mother to feel totally comfortable, the nurse may never be able to assess the maternal vital signs. Choose the midpoint: not before, not after, but between. A child admitted to rule out intussusception is scheduled for a barium enema. The nurse should teach the child's parents that the major purpose of this procedure is to: Confirm the diagnosis. Reduce the telescoping. Ease the passage of stool. Provide symptomatic relief. The definitive diagnosis of intussusception is based on a barium enema, which clearly demonstrates the telescoping of the bowel wall, which blocks the flow of the barium. Answer 2 is incorrect because although a secondary effect may be a nonsurgical reduction of the telescoping (which may occur due to hydrostatic pressure), this is uncertain and is not the main reason the procedure is performed. Answers 3 and 4 are incorrect because a barium enema is not administered to ease the passage of stool or provide symptomatic relief. Barium enema is a diagnostic procedure; therefore, the answer involves "diagnosis. If a woman is 3 months pregnant, what symptom or symptoms would the nurse's assessment most likely discover? Quickening. Lightening. Breast tingling and tenderness. Nausea and vomiting. These are common symptoms of pregnancy. Eighty percent of pregnant women experience breast tingling sensation during the first few weeks of gestation. Answer 1 is incorrect because quickening usually is not perceived until the sixteenth to eighteenth week of gestation. Answer 2 is incorrect because lightening usually occurs about 2 weeks before labor in the nullipara, and with the onset of labor in subsequent pregnancies. Answer 4 is incorrect because nausea and vomiting are not necessarily experienced by all women. Choose the nursing prenatal assessment that matches with the first trimester of pregnancy and the expected finding and outcome. The key is when, i.e., correct timing. A patient is to have a breast biopsy and possible mastectomy. Before going to see this patient the morning of surgery, the nurse assigned to assist her in the final preparations for surgery should first: Prepare the preoperative medication. Check to be sure the operative permit has been signed. Check to see if the preoperative laboratory reports have been placed in the chart. Check the diet orders to be sure the patient has been placed on the NPO list. Before any operative procedure can proceed, however minor, a voluntary, informed consent must be given. Answer 1 is incorrect: the nurse's third step is to check the time and the type of preoperative medication. Answer 3 is incorrect because before the nurse initiates preoperative care, charts should be checked first for operative consent and second for laboratory results, noting any abnormalities. Answer 4 is incorrect: the nurse must verify an informed consent in the chart before checking to be sure the patient has been placed on the NPO list. Once done, it is followed up by checking for the sign on the patient's bed when the nurse goes to help the patient prepare. This is priority question: first check for evidence of consent. The attending physician and anesthesiologist decide to administer spinal anesthesia for a cesarean birth. The nurse knows the amount of anesthesia used will be as minimal as possible because spinal anesthesia: Produces severe fetal depression. Causes maternal hypotension. Rapidly crosses the placenta. Depresses maternal respirations. Hypotension is even more severe when there has been bleeding. Answer 1 is incorrect because one of the advantages of spinal anesthesia is that it causes very little fetal depression. Answer 3 is incorrect because if administered properly, very little anesthesia should cross the placenta. Answer 4 is incorrect because it is irrelevant unless the mother has an adverse reaction to the anesthesia. First, decide if the effect is primarily on the mother or the fetus. Then eliminate the two options related to the fetus. Recall that spinal anesthesia affects BP, rather than respirations. A client's mother asks the nurse what caused her son to take drugs. The most therapeutic response would be: He probably wanted to be like his peers. Inappropriate limits were probably set on his behavior. It involves many factors. He felt isolated and unloved. There are no definite answers, because there are many possible causes of drug abuse. Many times not even the abuser can say why he or she began using drugs. Answer 1 is incorrect because although peer pressure may be a contributing factor, the nurse lacks validation. Answer 2 is incorrect because inappropriate limits is an invalidated assumption that would need to be explored further. Answer 4 is incorrect because although feelings of isolation and of being unloved may be contributing factors, the nurse again lacks validation. There is insufficient information in the stem to choose three of the options. Focus on the most general answer, based on lack of definitive data in the stem. At 2:30 A.M., the nurse hangs a 1000 mL bottle of IV fluid. If the IV infuses at 110 mL per hour as ordered, how much fluid should infuse by 6:00 a.m.? 385 mL. 500 mL. 615 mL. 740 mL. If the IV infuses at the proper rate, 110 mL per hour, from 2:30 a.m. to 6:00 a.m., 110 mL X 3.5 hours = 385 mL infused. Answers 2, 3, and 4 are incorrect calculations. Basic math, not a formula. When teaching the parents about an apnea monitor, the nurse should stress: Always respond to the monitor alarm immediately. Initiate CPR whenever the alarm sounds. A responsible adult must remain in the room with the infant at all times. Call the emergency department during any episodes of apnea. If the alarm sounds, the parents should always respond immediately. Answer 2 is incorrect because they should first check the infant's breathing and, if the infant is not breathing, they must start CPR immediately to prevent brain damage. However, if the infant is breathing normally when the alarm sounds, something technical is responsible for the alarm, and it would be inappropriate to begin CPR. Answer 3 is incorrect because having to remain with the infant at all times would defeat the alarm's purpose. The adult can leave the room if the infant is being monitored correctly. Answer 4 is incorrect because in terms of follow-up care, the physician and/or emergency department should be contacted, but only after the apnea has been successfully resolved; it is not appropriate to call the emergency department while the infant is apneic. Assess first; check the infant in response to the monitor alarm. On admission to the recovery room, a patient is very restless. The respirations are deep and somewhat irregular; the patient startles easily and moans at the nurse's touch. The best nursing action is: Continue to stimulate the patient by saying that the operation is over. Raise the side rails and remain quietly in attendance. Administer meperidine (Demerol) HC1, 100 nig IM. Check the nailbeds for cyanosis. Anesthesia is divided into four stages. Most surgical procedures are carried out in stage III, during which time the patient is unconscious and reflexes are depressed. As the patient eliminates the anesthetic agent, she or he goes into stage II, which is the stage of delirium or excitement. Respirations are exaggerated and irregular, and muscle tone is increased. To prevent injury during this stage, nursing measures are designed to reduce stimulation by maintaining a quiet, well-regulated environment. Answer 1 is incorrect because continued stimulation will only increase restlessness. Answer 3 is incorrect because pain medication may delay elimination of the anesthetic secondary to decreased respiratory excursion. Answer 4 is incorrect because although nailbeds should always be checked for signs of hypoxia, cyanosis only occurs with severe respiratory depression. Always think patient safety first? On the third day of hospitalization following an anterior MI, a patient becomes increasingly restless. Pulse rate has increased to 126 beats per minute. The first nursing action is to: Do a partial physical assessment, which includes vital signs, pulmonary auscultation, and cognitive functions. Ask if the patient is upset, because depression is common on the third day of hospitalization. Re-administer oxygen per nasal catheter (prongs or tongs) at 6 liters, because restlessness is an early sign of cerebral hypoxia. Decrease the rate of intravenous infusion to prevent fluid volume overload. An early indication of cardiac decompensation is tachycardia. Therefore, the patient's vital signs, mentation, and pulmonary status should be assessed to rule out this complication of myocardial infarction. Other causes of tachycardia are hypovolemia, anxiety, and pain. Assessment of pain and emotional status can be determined during cognitive assessment. Answers 2, 3, and 4 are incorrect because actions such as encouraging verbalization of feelings, administering oxygen, and decreasing the rate of intravenous infusion will be determined by the nurse's assessment of vital signs. Choose the first step of the nursing process: assess While observing a patient throughout a blood transfusion, the nurse should be alert to which possible sign of a hemolytic reaction? Urticaria. Polyuria. Flank pain. Hypothermia. Signs and symptoms of a hemolytic reaction usually include chills, shaking, fever, red (or black) urine, headache, and flank pain. Answer 1 is incorrect because urticaria is not a common sign in a hemolytic reaction, although it is common with an allergic reaction. Answers 2 and 4 are incorrect because neither polyuria nor hypothermia is a common sign in a hemolytic reaction. Recognize possible complications (kidney with hemolysis). A patient is awaiting the insertion of a pacemaker. The blood pressure is 128/60. Which medication should the nurse have available during this patient's preoperative period? Lidocaine (Xylocaine). Atropine sulfate. Digoxin. Propranolol hydrochloride (Inderal). Both atropine and isoproterenol (Isuprel) are kept available in the preoperative period as drugs of choice should the ventricular rate decrease further. Isoproterenol enhances pacemaker automaticity and facilitates AV conduction in heart block. Atropine acts to enhance AV conduction by inhibiting parasympathetic nervous system innervation of the AV node. Answer 1 is incorrect because lidocaine is an antiarrhythmic used to depress myocardial automaticity. Therefore, this drug would not be indicated should the patient's ventricular rate decrease in the preinsertion period. Answer 3 is incorrect because digoxin enhances vagal stimulation of the AV node, decreasing conduction through the node, and therefore would not be indicated should the patient's ventricular rate decrease in the preinsertion period. Answer 4 is incorrect because propranolol is a beta-blocker that depresses cardiac contractility and heart rate. This drug would not be indicated should the patient's ventricular rate decrease in the preinsertion period. Note pattern in drug effects: three slow or depress cardiac function.. In considering the equipment for Bryant's traction, the nurse should expect to see: A Kirschner wire in the fractured femur. A Steinmann pin in the fractured femur. Adhesive material taped to the skin of both legs. Adhesive material taped to the skin of the fractured leg only. Bryant's traction is a form of skin traction used in infants and toddlers with fractured femurs; when applied correctly, adhesive material should be taped to the skin of both legs. Answers 1 and 2 are incorrect because skeletal traction in the form of a Kirschner wire or Steinmann pin is not used in Bryant's traction. Answer 4 is incorrect because adhesive material should be taped to the skin of both legs, not one leg. Choose the option that is different: three options have one leg; one option involves both legs. Bryant's traction is always applied bilaterally. In providing health teaching for an expectant couple, what should the nurse tell them is a probable sign of pregnancy? Fetal heart sounds. Positive pregnancy test. Fetal movements felt by examiner. Outline of fetus on sonogram. Positive pregnancy test results are considered among the probable signs of pregnancy (with the exception of the bioassay test for the beta subunit of HCG, which is accurate). Answers 1, 3, and 4 are incorrect because hearing fetal heart sounds, feeling fetal movements, and seeing the fetus are all positive signs of pregnancy, not probable signs. The positive pregnancy test is a probable sign. Compare presumptive, probable, and positive signs of pregnancy. The physician suspects that a patient has a peptic ulcer. The nurse should expect the physician to order which diet after the first 48-72 hours? Small feedings of bland food. Frequent feedings of clear liquids. A regular diet given frequently in small amounts. NPO. Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload. Answer 2 is incorrect because clear liquids may not control the amount of acid in the stomach, would be monotonous, and may lack all the necessary nutrients. Answer 3 is incorrect because a regular diet may overload the system. Answer 4 is incorrect: NPO would promote the production of free acid in the stomach and increase the symptoms. Consider time element (first diet). A patient tells the nurse that there are big white ants crawling all over the wall. The most appropriate nursing response would be: Where are they? I'll kill them for you. You must be seeing things. Silence. I don't see any ants; but you seem afraid. This response does not contradict the patient's perceptions, is honest, and shows empathy. Answer 1 is incorrect because it "humors" the patient and is dishonest and non-therapeutic. Answer 2 is incorrect because it makes fun of the patient. Answer 3 is incorrect because it avoids the situation and makes the patient feel that the nurse does not care. Choose the answer that provides reality orientation and acknowledges feelings? In assisting a patient to prepare for immediate surgery, what would the nurse do? Remove the patient's wedding band. Begin exploring the patient's fears and anxieties about surgery. Assist in removing dentures and nail polish. Remind the patient to void following preoperative medication. Dentures, hairpins, and combs must be removed. Nail polish must be removed so cyanosis can be easily monitored by observing nailbeds. Answer 1 is incorrect because the wedding band is taped securely to the finger, not removed. Answer 2 is incorrect because in the short time available before surgery, although the patient should be allowed to voice concerns and should be given any needed support, time will not permit an extensive exploration of the basis of the patient's concerns. Answer 4 is incorrect because the patient should void before receiving medication, not afterward. Think patient safety first. A patient is to be discharged on the antihypertensive drug reserpine. The nurse's instructions to avoid intermittent hypotension would include: Rise slowly from sitting or lying. Ingest alcohol to prevent hypotension. Avoid cold weather, which precipitates attacks. Exercise to decrease sudden vasodilation. Hypertensive patients should be cautioned to make position changes slowly to prevent intermittent postural hypotension. Answer 2 is incorrect because alcohol may contribute to hypotension, not prevent it. Answer 3 is incorrect because cold causes vasoconstriction, not vasodilation associated with hypotension. Answer 4 is incorrect because exercise increases, not decreases, vasodilation. Correct choice is a common activity? The nurse administers preop medication, atropine (0.15 mg) IM. Fifteen minutes later, the patient is breathing rapidly and has a flushed, red face. The nurse should: Administer the atropine antidote stat. Give the patient a cool sponge bath. Tell the patient these are normal side effects of atropine. Page and advise the surgeon of the patient's condition before transporting the patient to the operating room. Atropine is a cholinergic blocker (parasympatholytic) used preoperatively to diminish secretions and to block cardiac vagal reflexes. Normal side effects include dry mouth; hot, dry, flushed skin; and tachycardia or palpitations. Thus, the patient can be safely told that these are normal, expected effects of atropine; in fact, this probably should have been included in the preop instructions, before the patient even received the medication. Answer 1 is incorrect because it would be unnecessary to administer the atropine antidote, which is physostigmine salicylate. Answer 2 is incorrect because it would be inappropriate to bathe the patient at this time. Answer 4 is incorrect because it would be unnecessary to page the surgeon. Know both the expected and untoward effects. Three options imply that there is a problem; one does not. Choose the option that is different in this case. The nurse has discussed important aspects of breast feeding with a new mother. To evaluate the effects of the teaching, the nurse asks her to put it in her own words. Which response indicates a need for further teaching? Rest and relaxation are essential. An adequate diet is important. Large breasts produce more milk. Birth control is necessary throughout breastfeeding if I don't want to become pregnant. Breast size is not as important as the amount of glandular tissue, because it is not the adipose tissue but the secreting tissues of the mammary glands that produce the milk. Answers 1 and 2 are incorrect responses because adequate diet and rest are essential to promoting lactation. Answer 4 is incorrect because she may ovulate and could become pregnant while lactating. When a question asks for the "need for further teaching," choose the incorrect answer; in this case eliminate the one that is a myth. A patient who has had a modified mastectomy begins to demonstrate some early signs of shock, such as increased pulse, cool, clammy skin, and restlessness. The nurse could enhance venous return by: Administering oxygen via mask to reduce restlessness. Keeping trunk flat and raising foot of bed. Placing her in Trendelenburg position. Wrapping her entire body in warmed blankets. Having the legs elevated (20 degrees) in a straight line, and the trunk horizontal, improves venous return to the heart and prevents abdominal viscera from impinging on the diaphragm. Answer 1 is incorrect because oxygen administration may have a palliative effect but does not affect venous return. Answer 3 is incorrect because the Trendelenburg position, after initially increasing blood flow to the brain, initiates a reflex mechanism that causes cerebral vasoconstriction. Answer 4 is incorrect: wrapping the patient in blankets will cause dilation of the peripheral vasculature, which will further decrease venous return. Visualize impact of choice on improving blood flow to heart. In discussing what clothes a toddler with eczema should wear, both in the hospital and at home, the nurse would be most correct in teaching the mother that this child should wear only: Cotton. Linen. Natural wool. Polyester blend. To prevent exacerbating the eczema, it is generally recommended that the child wear pure, natural cotton clothing only. Answers 2, 3, and 4 are incorrect because linen, wool, and polyester blends are more likely to cause worsening of the eczema. Because of the allergic nature of eczema, any food or clothing should be hypoallergenic. The physician orders a soapsuds enema for a woman in preterm labor whose membranes have ruptured. The most appropriate nursing action would be to: Administer the enema as soon as possible. Recheck the order for the type of enema. Refuse to administer the enema because this is a preterm labor and membranes have ruptured. Ask the physician to check the fetal position before giving the enema. Enemas are not administered when there is vaginal bleeding or preterm labor or when the fetus is in an abnormal presentation or position. Answer 1 is incorrect for the same reason. Answer 2 is incorrect: soapsuds enemas are contraindicated because they are potentially dangerous due to their physiological incompatibility with the lower gastrointestinal tract. Answer 4 is incorrect: though the fetal position must be assessed before administering an enema, enemas are not administered in these circumstances. The decision to make in choosing the best answer here is whether or not enemas are OK in this case. Because they are not, choose the option in which the enema is not given (i.e., "Refuse ..."). While doing chest compressions during CPR on an adult, the nurse hears a "cracking" sound. The appropriate response would be to: Stop chest compressions immediately and ventilate only. Compress no more than 1.5 inch. Check for proper hand placement and continue. Have someone else who is not as strong do compressions. Broken ribs may occur even with proper CPR technique, particularly when performed on the elderly. The nurse should check that the hands are positioned properly, then continue CPR even if the cracking continues. Broken ribs will heal, whereas stopping compressions (Answer 1) will likely result in the patient's death. Compressing less than the standard of 1.5 to 2 inches (Answer 2) will be ineffective on an adult. Individual strength (Answer 4) is irrelevant; proper hand position and depth are essential for anyone doing CPR. First step in the nursing process assess technique. A pregnant woman verbalizes concern about the possibility of having to remain hospitalized for the next 8 weeks because of her preeclampsia. The most therapeutic response the nurse could make would be: It may not be that bad if you keep busy. Tell me how you are feeling. I'll sit with you a while. Maybe you should tell your doctor how you are feeling. This response is open ended and will elicit the most information. Answer 1 is incorrect because it merely provides false reassurance and trivializes her feelings. Answer 3 is incorrect: although it may be a therapeutic response, it is a short-term intervention unless the nurse consistently sits with the woman for a while every day. If possible, the same nurse should be assigned to her each day. Answer 4 is an inappropriate nursing intervention because the nurse can work in conjunction with the physician to provide psychological support. Eliminate the response that minimizes the patient's concern (1) ; the response that is OK but it does not focus on the patient's feelings (3) ; and the response that "passes the buck" to the MD (4). A patient should be able to describe signs of pacemaker malfunction. Which behavior would indicate that this goal has been met? Counts pulse correctly and identifies need to monitor rate daily. Counts pulse correctly and identify the significance of drainage or discoloration around the battery insertion site. Counts pulse correctly, states the estimated life of the battery, and understands need for prophylactic replacement. Counts pulse correctly and identifies need to report rate changes and symptoms such as dizziness, palpitations, and hiccoughs. Periodic checks on pacemaker function are essential and may be accomplished by pulse taking, frequent ECGs, or telephone transmission of ECG. Generally, rate changes greater than 15 beats should be reported to the physician; so should symptoms such as syncope, dizziness, hiccoughs (diaphragmatic stimulation), dyspnea, chest pain, and fluid retention. Answer 1 is incorrect because it is incomplete. The patient must also report rate changes and symptoms. Answer 2 is incorrect because drainage and discoloration refer to indicators of infection. Answer 3 is incorrect: although estimating battery life indicates that the patient understands the battery pack has a limited life expectancy, the answer is incomplete. There are two correct responses; choose the one that is more complete. A pregnant woman is in early labor; she has a history of drinking alcohol and of smoking cigarettes and marijuana, although she stopped when she learned she was pregnant. Her husband expresses some concern over his wife's previous smoking habits. The nurse should inform him that: Although she no longer smokes, she was exposed to cigarette and marijuana smoke, which could affect her pregnancy. She is assured of a healthy infant because she stopped smoking as soon as she knew she was pregnant. The early labor is probably due to her smoking marijuana. Alcohol is considered much safer than marijuana. This is the most appropriate and honest response. However, it is essential to answer the question clearly, without stimulating unnecessary fear. Answer 2 is incorrect because there is no way to guarantee the birth of a healthy infant. Furthermore, the woman smoked early in her pregnancy, the period of organogenesis when the conceptus is most susceptible to teratogenic effects. Answer 3 is incorrect: there is no way to absolutely validate this. Answer 4 is incorrect because there are no definitive data to support such a claim. Look at the verbs and choose Answer 1 as the least definitive in this case: "could affect" (1) , "is assured" (2) , "is due to" (3) , "is considered" (4). A patient with a left leg fracture is to be taught the three-point gait before discharge. This patient should be given which instruction by the nurse? Advance your right crutch, swing the left foot forward, advance the left crutch, and then bring the right foot forward. Move your right crutch and left foot forward together, and then swing the right foot and left crutch in one movement. While partially bearing weight on your left leg, advance both crutches and then bring your right leg forward. Using one movement, advance your left foot and both crutches and then bring your right leg forward. In the three-point gait, both crutches and the affected "bad" leg and foot are moved together, with the unaffected "good" leg and foot following. Answers 1 and 2 are incorrect because the crutches are both moved simultaneously, not independently. Answer 3 is incorrect because the patient should not bear any weight on the fractured leg when using the three-point gait. Visualize each answer. Which one avoids weight bearing? Immediately postoperative, after general anesthesia, a patient has an airway in place and is in a supine position. To prevent airway obstruction, the nurse should: Leave the airway tube in and turn the patient's head to the side. Maintain the patient's present position. Remove the airway tube and turn the patient's head to the side. Remove the airway tube and maintain the patient's prone position. The airway tube should remain in place and the patient's head should be turned to the side to prevent obstruction of the airway by the tongue and to allow secretions to drain from the mouth. Answer 2 is incorrect because the head is not turned to the side. Answers 3 and 4 are incorrect because the airway tube should never be removed until the patient is alert enough to begin attempting to eject it. Leaving the airway tube in after this point may cause vomiting due to stimulation of the gag reflex. Think patient safety as a priority. A patient with a history of substance abuse asks the nurse not to tell anyone about the patient smoking a marijuana joint in the hospital room, and the patient promises to never do it again. The nurse should realize that this patient is mostly: Being sincere and wanting to change. Seeking attention. Being manipulative. Trying to avoid punishment. Attempting to control the situation and do as the patient pleases is most likely the patient's primary goal, in light of the history of drug abuse. Bending the rules for a severe violation of hospital policy, the treatment, and the law is not justified. For Answer 1 to be correct, the nurse would need further evidence of the patient's desire to change, such as overt, consistent changes in the patient's pattern of behavior and open verbalization of feelings. Answers 2 and 4 are incorrect because they are aspects of manipulation. Review the concept of manipulation. The nurse can expect increased restlessness in a patient with tachycardia following an anterior myocardial infarction because: Decreased ventricular filling time results in decreased venous return and cerebral edema. Palpitations result in anxiety. Decreased ventricular filling time always results in decreased cardiac output and tissue perfusion. A significant decrease in stroke volume may occur, causing a decrease in cardiac output. Tachycardia decreases diastole, which decreases ventricular filling time and stroke volume. A significant decrease in stroke volume will result in a concomitant fall in cardiac output and tissue perfusion. Decreased cerebral perfusion and cellular hypoxia will result in signs of increased restlessness, anxiety, apprehension, and irritability. Answer 1 is incorrect because to prime the pump, venous return is enhanced by the activation of circulatory reflexes, not depressed. Answer 2 is incorrect because tachycardia is the result of increased sympathetic nervous system stimulation of the heart and may result in the patient's awareness of his or her heartbeat, thus increasing anxiety. Answer 3 is incorrect because decreased cardiac output and tissue perfusion only occur at very high rates or when myocardial contractility is compromised, as with myocardial infarction. Recognize expected outcome from physiological response. To evaluate a mother's understanding of the discussion about Down syndrome, the nurse would ask her to explain the syndrome in her own words. Which response indicates a need for further health teaching? Down syndrome is an abnormality that can result from an extra chromosome. Only children born to older women have Down syndrome. A test can be done to diagnose Down syndrome while the fetus is still in utero. Down syndrome includes a form of mental retardation. Down syndrome is due to chromosomal aberration and, although trisomy 21 is more common in infants of older women, another form, mosaicism, occurs in pregnancies of women of all ages. Answer 1 is incorrect because an extra chromosome is implicated in the development of Down syndrome. Answer 3 is incorrect because amniocentesis at or after 16 weeks of gestation can successfully identify the presence of this abnormality. Answer 4 is incorrect because varying degrees of mental retardation do accompany Down syndrome. When the question asks when further teaching is necessary, choose the incorrect answer. Understand the chromosomal abnormalities associated with Down syndrome and incidence of occurrence. A patient is to have an above-the-knee (AK) amputation for severe vascular insufficiency and gangrene of the foot. The best explanation by the nurse for why the patient is to have this amputation would be: The degree of vascular insufficiency is extensive. AK amputees are better suited for a prosthesis. The higher the amputation, the less energy required for rehabilitation of balance and walking. Below-the-knee amputation heals less successfully. Above-the-knee amputations are often necessary because of the extent of the disease. The most critical factor in determining the level of the amputation is the adequacy of the arterial blood supply. Answer 2 is incorrect because it describes the advantages associated with a below-the-knee amputation. Answer 3 is incorrect because an above-the-knee amputation requires more energy for rehabilitation and walking. Answer 4 is incorrect because a below-the-knee amputation not only heals faster than does an above-the-knee amputation, but it is less painful postsurgically, less psychologically disturbing, and less prone to contractures. See a pattern? Three choices deal with a postoperative concern. The correct choice explains the initial decision. The proper method of suctioning a tracheostomy tube includes: Suctioning only while inserting the catheter. Suctioning only while withdrawing the catheter. Suctioning during both insertion and withdrawal of the catheter. Suctioning on insertion only if secretions are copious. Suction is applied only after the catheter is in place and ready for withdrawal. Applying suction intermittently and rotating the suction catheter assist in reducing the negative pressure effects of suctioning. Suctioning should be limited to periods of 10-15 seconds. Answers 1, 3, and 4 are incorrect because of the negative effects these actions would have on patient aeration. Proper and safe technique: three choices include during "insertion." In assessing a woman in labor following the administration of spinal anesthesia, the nurse should realize that if she can wiggle her toes: The effect of the spinal anesthesia has dissipated. She may still become hypotensive. This behavior is essentially meaningless. She is prone to hypertension. Wiggling the toes indicates that the motor block caused by the spinal is wearing off. However, the autonomic block is still present, and the woman may experience hypotension (not hypertension). Answer 1 is incorrect because the autonomic block is still present even though the effects of the anesthesia are wearing off. Answer 3 is incorrect because wiggling the toes indicates that the motor block caused by the spinal is wearing off and is therefore not meaningless. Answer 4 is incorrect because the woman may experience hypotension. In this question, focus on two contradictory options: hypotensive vs. hypertension. Remember: a spinal causes decreased BP. To help a preschooler cope most effectively with repeated painful injections of EDTA, the nurse should: Teach the mother the importance of bringing favorite toys. Encourage the child to spend most of the day in the playroom, engaged in free play. Offer the opportunity for therapeutic play. Allow play with other preschool children as much as the child wants. The most effective intervention to help preschoolers cope with painful experiences during hospitalization is to offer the opportunity for therapeutic play with puppets or dolls and medical equipment. This type of play experience allows the child to "act out" frustrations and anger in a safe, controlled manner, enabling the child to work through feelings about a difficult experience. Answers 1, 2, and 4 are incorrect because playing with toys, engaging in free play, and playing with other children are not as effective as offering an opportunity for therapeutic play. Therapeutic release of feelings (pain) is accomplished best via therapeutic (medical) play. Which arm position will best facilitate venous return on the operative side of a patient who has had a modified mastectomy, and reduce the occurrence of lymphedema? Semi-Fowler's position with the elbow flexed and the arm across the chest. Low Fowler's position with the arm elevated so that the hand and elbow are slightly higher than the shoulder. High Fowler's position with the elbow flexed and the right hand positioned next to the head. Adduction of the shoulder, extension of the elbow, and flexion of the wrist. Low Fowler's to semi-Fowler's position with the arm elevated on pillows so that the wrist and elbow are slightly higher than the shoulder best facilitates venous return, reducing the occurrence of edema. Some physicians may order that the patient be positioned so that the hand is raised above the head. Answers 1, 3, and 4 are incorrect because venous return is not enhanced, or muscle contractures may possibly develop. Visualize the position of the arm. The most important aspect of treatment for a client who is a substance abuser is: Teaching the client about the hazards of taking drugs. Informing the client that using drugs is illegal. Encouraging the client to want to change behavior. Assisting the client to develop alternative coping mechanisms. The treatment of drug abuse is only effective if the client is motivated to make changes in style and pattern of living. Although the hazards of drugs (Answer 1), the fact that using drugs is illegal (Answer 2), and developing alternative coping mechanisms (Answer 4) are all significant components to be incorporated in health teaching, the client must first be motivated to learn. Key phrase is "most important aspect of treatment"; in this question, "motivation" precedes other choices. Two hours after a child returns to the unit following cardiac catheterization, the dressing is soaked with bright-red blood. The nurse first reinforces the dressing. What should the nurse do next? Check vital signs. Increase the flow rate of the IV. Place the child in reverse Trendelenburg position. Notify the cardiologist. After marking the original dressing (to indicate the extent of the bleeding) and reinforcing the dressing (to prevent infection), the nurse should check the vital signs to determine if the bleeding episode has had any effect on the child's physiological status. Answer 2 is incorrect because in general the nurse should never change the flow rate of the IV without a physician's order. Answers 3 and 4 are incorrect because after checking vital signs, depending on the status of the bleeding and the vital signs, the nurse might change the patient's position and notify the cardiologist. Look at the verbs; select a verb that assesses ("check" before "increase," "place," or "notify"). Assessment is the first step of the nursing process. New parents express concern about when they can resume intercourse. After validating the information with the physician, the nurse would inform the couple that: Generally it is a good idea to wait until after the sixth-week postpartum checkup. If there are no unforeseen problems, 3 weeks is usually the recommended waiting time. The couple may have sex as soon as they arrive home from the hospital, as long as the mother feels up to it. The couple should wait until the mother ceases to breastfeed. All physicians and institutions have their own guidelines. However, 3 weeks is generally appropriate if the lochia has decreased and becomes fairly clear in color, and if there are no other problems. Answer 1 is incorrect because 6 weeks is longer than is usually necessary. Answer 3 is incorrect because when they arrive home is too soon. Answer 4 is incorrect because waiting until breastfeeding ceases is longer than is usually necessary The key factor is best timing when: not too soon ("as soon as ... arrive home"); not too long (6 weeks, or when she stops breast feeding). A patient is awaiting the insertion of a permanent pacemaker because of complete heart block. The nurse knows that isoproterenol hydrochloride (Isuprel) is used for this patient because of which effect? Beta-mimetic. Cardiac glycoside. Anticholinergic. Beta-blocker. Isoproterenol is categorized as a beta-mimetic, in that its action simulates beta-adrenergic discharge. Actions include increased strength of cardiac contraction, increased heart rate, and decreased venous pooling, which increases venous return. An additional effect of isoproterenol is increased myocardial consumption resulting from increased rate and contractility. Isoproterenol is not a cardiac glycoside (Answer 2) like digoxin, an anticholinergic (Answer 3) like atropine, or a beta-blocker (Answer 4) like propanolol. Recognize expected drug effects. A pregnant woman is hospitalized for preeclampsia. She and her husband express anxiety about having limited insurance, which may not cover this hospitalization. The most appropriate nursing intervention would be to: Refer the couple to social services for possible assistance. Initiate a family-counseling referral. Provide supportive counseling. Assess the couple's needs through discussion. An effective assessment of the couple's needs is obtained through discussing the couple's own perceptions of those needs. Answers 1 and 2 are incorrect: although referral to social services or family counseling may be an appropriate action once a thorough assessment is complete, it should never precede discussion with the couple. Answer 3 is incorrect: although supportive counseling may be an appropriate action once a thorough assessment is complete, it also should never precede discussion with the couple. Choose "assess" before "refer" or "provide." Review the nurse's role as patient advocate and guidelines for proper referral. A patient has had an above-the-knee amputation on the left side. While being repositioned onto the abdomen, the patient cannot turn because the "left foot is causing too much pain." The first response by the nurse should be: To insist that the patient lie on the abdomen. To ignore the comment and state that the nurse will return later. To discuss the principle of phantom pain after amputation. To offer some form of pain control. Phantom limb pain or sensation is an unpleasant complication that sometimes follows amputation. This phenomenon is not completely understood but is believed to result from afferent nerve fibers (sensory) severed during surgery. The pain in the limb may be identical to that perceived by the patient before surgery. The patient needs to be aware of the nature of this discomfort. Sometimes the sensation will disappear if the patient looks at the stump and recalls that the limb has been amputated. In cases where discomfort persists, alcohol may be injected into the nerve endings for temporary relief, the nerve endings may be removed, or on rare occasions reamputation may be required. Answers 1 and 2 are incorrect because they negate the patient's perceptions of discomfort and avoid the issue. Answer 4 is incorrect: an explanation of the phenomenon and other palliative measures should precede the administration of a narcotic. First response: address the patient's comment. During a pre-discharge teaching session for a patient who has had a permanent pacemaker inserted, the patient's wife states, "Don't worry, I'll be sure that he obeys the doctor's orders to the letter." The nurse's best response would be: I can see that with your help, he should do just fine. Are you worried? I'm not worried. You both have a lot of common sense. This has been a difficult period for both of you. Can you foresee any problems with these instructions? Conflicts concerning discharge instructions following myocardial infarction and pacemaker insertion are common. When the nurse prepares a patient for discharge, it is important to recognize that both patient and spouse may have several fears they have not verbalized. Allow time for and encourage verbalization of feelings. Likewise, be sure that discharge instructions are feasible for the individual's lifestyle; if they are not, work out a plan of modification with the patient, family, and physician. Referral to a community health nurse or local cardiac rehabilitation support group may also facilitate the rehabilitation. Answers 1, 2, and 3 are incorrect because they cut off the patient's and spouse's range of response and may therefore preclude obtaining pertinent data. Look for the broadest response. In planning initial care for an adolescent client who is a substance abuser, the nurse should: Be very direct with the client. Allow the client to make all the decisions about his or her care. Help the client to feel very secure to prevent anxiety. Encourage the client to begin to depend on others. Straightforward, direct communication is needed to keep the client from manipulating his or her care. The nurse needs to be honest and to set firm limits. Answer 2 is incorrect because an adolescent drug abuser tends to be very manipulative; however, allowing the client to assist in the decision-making process is essential. Answer 3 is incorrect because too much security will foster dependence. The client needs to identify and begin to cope with the anxiety, although anxiety generally cannot be eliminated entirely. Answer 4 is incorrect because drug abusers are already characteristically very dependent individuals. Concept of manipulation is operative here, requiring direct communication. Upon return from the OR at 11:30 A.M., a patient has 425 mL left in an IV bag of 5% dextrose and 1/2 NS. The postop MD orders include "IV to infuse at 320 mL every 8 hours." When should the nurse anticipate having to change the IV bag? 3:00 p.m. 6:00 p.m. 9:00 P.M. 12:00 midnight. Per MD order, the TV should infuse at 320 mL every 8 hours, or 40 mL per hour. Thus, if there is 425 mL left in the IV and it runs at 40 mL per hour, the present bag should last 10 hours, or from 11:30 a.m. to 9:30 P.M. The nurse should plan to change the bag at 9:00 p.m., before it runs out completely. Answers 1 and 2 are incorrect because changing it earlier would waste IV fluid, which is costly. Answer 4 is incorrect because changing it later would mean the IV would run out completely, which may result in an embolism or a clogged IV line. Basic math, no formula required. The nurse's assessment of a patient in pulmonary edema would reveal: Rapid respiration, frequent cough, flushed face. Persistent cough, rapid respiration, hemoptysis. Dyspnea, hacking cough, purulent sputum. Air hunger, orthopnea, elevated temperature. As the capillary pressure in the lungs increases from cardiac decompensation, fluid pours from the circulatory system, across the capillary membrane into the alveoli, bronchi, and bronchioles. Typical manifestations include a respiratory rate as high as 6070 breaths per minute and a persistent cough with expectoration of large amounts of frothy, blood-tinged sputum (hemoptysis). Answer 1 is incorrect because the patient's face will be pale, not flushed. Answer 3 is incorrect because the cough is productive, not hacking, and purulent sputum would be seen with an infection such as pneumonia. Answer 4 is partially correct, except the patient in pulmonary edema will show signs of shock and be cold, most likely with a subnormal temperature. Use a process of elimination. Visualize lungs filling with fluid. Before entering a patient's room, the nurse should wash her or his hands for a minimum of: 10 seconds. 30 seconds. 45 seconds. 60 seconds. To be sure a typical antimicrobial will have the desired effect, it must be in contact with the skin for a minimum of 10 seconds. Answers 2, 3, and 4 are incorrect because durations longer than 10 seconds are not necessary. The minimum duration of time for proper hand washing is approximately equal to the amount n of time it takes to whistle one stanza of the tune "Yankee * Doodle Dandy" (about 10 seconds). The nurse in the recovery room is monitoring the patient's vital signs every 15 minutes. Which change should be reported immediately to the surgeon? Dry, cool skin. A systolic blood pressure that drops 20 mm Hg or more. A diastolic pressure below 70. A pulse rate that increases and decreases with respirations. A drop in the systolic blood pressure of 20 mm Hg or more below the preoperative blood pressure is indicative of impending shock. Shock may be due to hemorrhage, vasodilation caused by anesthesia, insufficient fluid replacement, or abnormal clotting. Answer 1 is incorrect because skin may be dry and cool in the immediate postoperative period because of normal temperature-regulating mechanisms, that is, vasoconstriction due to skin exposure in the operating room. Answer 3 is incorrect because a diastolic reading below 70 mm Hg is significant only if it is abnormal for the patient and is accompanied by a drop in systolic or a narrowing pulse pressure. Answer 4 is incorrect because pulse rates normally increase and decrease with respirations to some extent because changes in intrathoracic pressures affect venous return. This phenomenon, however, is more evident in children. Recognize changes from normal - most life threatening. The preoperative medications ordered by the anesthesiologist are morphine sulfate, 15 mg, and atropine S04, 0.4 mg, subcutaneously. The nurse can expect to give these drugs: Right before the patient leaves for surgery. 45-60 minutes before anesthetic induction. 20-30 minutes before anesthetic induction. 10-15 minutes before anesthetic induction. To reduce anxiety and ensure ease of induction, a preoperative medication should be administered 4560 minutes before anesthesia. Side rails should be raised after administration of medication, because the patient will begin to feel drowsy and light-headed. Answers 1, 3, and 4 are incorrect because giving medication less than 4560 minutes before induction of anesthesia would not allow sufficient time for the medication to reach its peak effect. Correct answer is broadest and most optimal for desired outcome. The nurse knows that a person who is on a bland diet may lack which essential nutrient? Vitamin C. Carbohydrates. Protein. Vitamin A. The patient should be given diluted orange juice to ensure an adequate supply of ascorbic acid (vitamin C). Answers 2, 3, and 4 are incorrect because carbohydrates, protein, and vitamin A can be easily obtained by ensuring a variety of foods in the bland diet. Choose the option that would potentially increase acid (ascorbic acid). When assessing a client who has been abusing amphetamines, the nurse would expect to see which symptom? Bradycardia. Increased irritability. Hypotension. Constipation. Although in moderation these drugs produce feelings of well-being and alertness, an overdose of amphetamines causes an increase in tension and irritability. Answers 1 and 3 are incorrect because an increase in the heart rate and blood flow is exhibited (these drugs stimulate the release of norepinephrine). Answer 4 is incorrect because diarrhea, not constipation, is a common side effect. Review signs and symptoms of amphetamine abuse. Which action is least likely to be within the role and legal responsibilities of the nurse who is assisting with an amniocentesis? Informing the woman about the risks involved in amniocentesis. Explaining/reinforcing how the procedure will be done. Monitoring the fetal heart rate. Observing the woman for signs of bleeding or contractions after the procedure is completed. Obtaining consent and informing the woman about the risks involved are legally the physicians role. The nurse's role is to reinforce the physician's teaching and to confirm that the information has been given to the woman. Answer 2 is an incorrect response because it is an appropriate nursing action to reinforce the physician's teaching and to confirm that the information has been given to the woman. Answers 3 and 4 are incorrect because monitoring the fetal heart rate and observing for bleeding are both appropriate nursing actions. When asked to choose the least likely, choose an incorrect answer. Review the nurse's legal responsibilities regarding informed consent for procedures. When noticing that a patient's IV site appears red and swollen, the nurse should: Apply warm soaks. Decrease the flow rate. Elevate the IV site. Remove the IV. If it appears that the patient's IV has infiltrated (site is red and swollen), the only acceptable action by the nurse would be to remove the IV line. Answer 1 is incorrect: after removing the IV line, the nurse might apply warm soaks if the area appeared reddened. Answer 2 is incorrect because the nurse should not increase or decrease the flow rate without a physician's order. Answer 3 is incorrect because elevating the site would further slow the flow rate, although IV fluids would continue to drip into tissue and might cause damage to the surrounding area. Priority: immediate action. Safety is the priority of care; only one action stops the procedure. Two weeks after a cast is applied, a foul odor is detected at the lower end of the cast. A window is made in the cast over the infected area and an antibiotic is prescribed. After 3 days on antibiotic therapy, which effect would be most indicative of a therapeutic response? White blood cell count is 7900/mm3. Temperature is 99.4 F. No complaints of pain. Appetite is fairly good. The most objective measure of the effectiveness of an antibiotic is a return of the white blood cell count to normal. Answer 2 is incorrect because a low-grade temperature may indicate a lingering infection. Answers 3 and 4 are incorrect because no pain and a good appetite are both good clinical indicators, but not as objective or as clearly measurable as the white blood cell count. Key term is "most indicative" of a therapeutic response (no infection). On completion of a nursing assessment, the nurse concludes that the patient is showing signs of increased intracranial pressure. Data to support this conclusion would include: Decreased blood pressure, tachycardia, and tachypnea. Increase in level of consciousness. Dilation of the pupil on the side opposite the hematoma. Bradycardia, increased pulse pressure, and Biot's breathing. The classic vital sign changes in increased intracranial pressure are known as Cushing's reflex. The pressure on the vasomotor center in the brain produces a slowing of the heart rate (bradycardia), an increase in the pulse pressure in an attempt to increase cerebral perfusion pressure, and an irregular breathing pattern (e.g., Biot's or ataxic, Cheyne-Stokes, apneustic). Answer 1 is incorrect because the vital sign changes indicate shock and are the opposite of increased intracranial pressure. Answer 2 is incorrect because the level of consciousness, rather than increasing, will decrease, which may be indicated by an unconscious patient becoming nonresponsive to painful stimuli. Answer 3 is incorrect because pupil dilation will occur when there is compression of cranial nerve 111 (oculomotor) on the same side as the injury or hematoma, not the opposite side. Recognize expected outcome; changes are opposite of shock. Ten days after the birth of their infant, a new father is concerned about the mother's mood. He states that she is tearful and apathetic and does not eat much. What would be the nurse's most appropriate response? Many women experience some degree of depression after the birth of a baby. I will suggest a psychiatric referral to assist her in coping with this crisis. I will notify the physician of your concern and ask the physician to prescribe an antidepressant for her. You need to be patient since these symptoms will dissipate. Many women experience some slight to moderate depression. Sleep deprivation and an inadequate support system may contribute to the "blues." Answer 2 is incorrect: if the behaviors become severe (i.e., persistent over a long period of time and increasingly exaggerated), then professional help should be initiated. Answer 3 is incorrect because a physician's referral may not be necessary and it is not the nurse's job to ask the physician to prescribe antidepressants; medication may not even be needed. Answer 4 is incorrect because the new father should be informed that patience, understanding, and help with housework and care of the infant are needed, and may help decrease some of the mother's anxiety. The key concept being tested is using a support system. Address the father's concern directly with correct health teaching rather than jump to make a referral (Answers 2 and 3). A patient with diabetes is NPO before surgery. An appropriate nursing measure on the day of surgery is: To withhold the daily insulin dose. To administer the daily insulin dose. To administer the insulin and request that the patient drink a glass of juice. To request specific orders regarding insulin administration. All insulin-dependent diabetics are to receive daily insulin. However, the physician should write specific orders for insulin coverage on the day of surgery. The reason for this is that both the physical and the psychological stresses of surgery tend to increase serum-glucose levels via glycogenolysis, and the patient's usual insulin may be insufficient. Answer 1 is incorrect because all insulin-dependent diabetics are to receive daily insulin. Answer 2 is incorrect because the physical and psychological stresses of surgery tend to increase serum-glucose levels via glycogenolysis, and the patient's usual insulin may be insufficient. Frequently, a rainbow coverage of regular insulin is ordered to supplement or temporarily replace daily doses of NPH or other longer-acting insulins. Answer 3 is incorrect because the patient is not given fluids before surgery, particularly if a general anesthetic is to be administered. Correct choice is the broadest. A patient with hallucinatory behavior constantly asks the nurse to bring French fries and a piece of apple pie. The nurse should realize that this patient is probably: Starving. Hallucinating. Disoriented. Playing a game. The patient is disoriented to time, place, and person and needs constant monitoring and comprehensive support. Answer 1 is incorrect: although the patient may be physiologically hungry, this is difficult to validate because the patient is confused. Answer 2 is incorrect because although the patient may be hallucinating, the information given here merely implies that the patient is disoriented. Answer 4 is incorrect because the patient does not appear to be in touch with reality. Hallucinatory behavior and disorientation go together. In caring for a patient with a double-lumen tracheostomy tube, the inner cannula should be removed and cleansed with hydrogen peroxide and normal saline: Only as necessary. Every 2-4 hours. Once a day. Never - do not remove the inner cannula for any reason. During the early postinsertion period, the inner cannula is removed using aseptic technique every 2-4 hours for cleansing. If secretions are copious or very viscous, more frequent cleansing may be necessary. If the patient is receiving oxygen therapy or is on mechanical ventilation, these treatments are continued through the outer cannula. Answer 1 is incorrect because routine cleansing is done, even when it appears unnecessary. Answer 3 is incorrect because once a day is not frequent enough. Answer 4 is incorrect because the cannula must be removed for cleansing. Look for the "ideal" frequency of cleansing and secretion management. Assessment of a woman in labor reveals the following: 4 cm dilated cervix, intact membranes, mild to moderate contractions every 4-6 minutes, alert affect. The nurse determines that this woman is in which stage of labor? First. Second. Third. Fourth. The first stage is the stage of the cervix. The woman's cervix is dilated only 4 cm, with contractions occurring every 4-6 minutes, and she is alert. Answer 2 is incorrect because the second stage is the stage from a 10 cm dilated cervix to full birth of the baby. Answer 3 is incorrect because the third stage is the stage of the placenta. Answer 4 is incorrect because the fourth stage is the period of recovery, usually the first 2 hours after birth. These are early changes; therefore, select the earliest phase. The best antimicrobial agent for the nurse to use in hand washing is: Soap and water. Isopropyl alcohol. Hexachlorophene (PhisoHex). Chlorhexidine gluconate (CHG) (Hibiclens). CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time. Answer 1 is incorrect because soap and water, although recommended for most general patient care, is not an antimicrobial. Answer 2 is incorrect because alcohol will degerm skin rapidly but, because of its drying effect on the skin, it is not recommended for repeated washing. Answer 3 is incorrect because hexachlorophene acts primarily on gram-positive bacteria and has also been associated with neurotoxicity; it is no longer recommended. Use process of elimination (and the longest answer!) The nurse knows that the proper technique for two-person CPR includes: Two full breaths followed by five compressions. A brief pause between rescue breathing and compressions. Rescuers changing positions every 5 minutes to prevent fatigue. A slower rate than is used in one-person CPR. The person doing compressions should allow for a full breath to be given before starting the compressions. Without the pause, the patient will not receive sufficient ventilation. The ratio is one full breath to five compressions, not two breaths (Answer 1). The persons doing CPR may change positions as needed; the protocol does not specify the time (Answer 3). The compression rate for two-person CPR is the same as the rate for one-person CPR: 80-100 compressions per minute, not slower (Answer 4). Know the "recipe" for effective CPR. A patient is taking nitroglycerin to control angina. Patient teaching regarding administration of nitroglycerin includes the importance of notifying the physician if repeated doses do not relieve chest pain. Additional information would include: Notifying the physician if headaches occur. Storing the medication in the refrigerator. Taking nitroglycerin prophylactically before exercise. Ingesting the tablets with liquid. Patients must be taught to place a nitroglycerin tablet under the tongue before exercising, eating a large meal, emotionally stressful events, and sexual activity. Answer 1 is incorrect because headaches following drug use are to be expected, but lessen over time. The physician does not need to be notified unless repeated dosages (3-5 tablets) do not relieve the pain. Answer 2 is incorrect because the medication should be stored in a dark bottle in a dry location. Refrigeration is not appropriate. Answer 4 is incorrect because the tablet is placed under the tongue and allowed to dissolve completely, and the saliva is retained briefly before swallowing. Swallowing whole with liquid will negate the drug's effectiveness. Only one answer deals with when the drug should be taken. The mother of a recently deceased infant insists on seeing the infant's body before leaving the hospital. The most therapeutic nursing action includes: Arranging for her to see the infant's body. Discussing this with the family's priest. Informing the father that seeing the infant's body would be detrimental to the mother's health. Telling the parents that hospital policy forbids her seeing the infant's body. This is a health team decision that needs to be supported by the hospital administration in order to assist the family in working through the grieving process. Answer 2 is incorrect because it may be a violation of the family's privacy. The priest's input may be considered, if the family requests it. Answer 3 is incorrect because it is an inappropriate assumption that would need further validation. Answer 4 is incorrect because it should not be standard policy in any hospital today. It is essential for many families to see the deceased in order to work through their grief. The concept here is grief. The best answer allows the mother (who is the focus of the question) to grieve. Eliminate Answers 3 and 4 because these options do not allow the mother to grieve. Eliminate Answer 2 (the priest) because it moves the focus away from the mother. A woman is to have a cesarean birth. Her partner asks the nurse whether he will see any "gore" or blood during the operation. The most realistic response would be: I'm not sure. It depends on the technique the physician uses Probably not, because a drape keeps the operation from view by both of you, if you sit by her head. Yes, blood and tissue will be all over the table. In most cesareans a drape is used and one can see very little "gore" or blood. Answer 1 is incorrect because the nurse needs to find out what the procedure usually involves. Answer 2 is incorrect because in almost all hospitals a drape of some type is used. Answer 4 is incorrect because it is not true. When the question asks for the most realistic response, identify and eliminate the ones that are not realistic first. In this case, the longest answer is the most complete, accurate, and realistic. You can also sound out the options and eliminate Answers 1 and 4 because they are "turn-offs." Answer 2 leaves the partner "hanging" without a helpful response. If a patient's antihypertensive drug therapy is effective, the nurse would expect: A greater decrease in systolic than diastolic pressure. A greater decrease in diastolic than systolic pressure. An approximately equal decrease in both systolic and diastolic pressures. Little change in blood pressure initially, but pulse will slow. Both systolic and diastolic pressures should decrease as a result of the pharmacological interventions. Answer 1 is incorrect because vasodilation and decreases in fluid volume decrease peripheral resistance, thereby lowering the diastolic pressure. Answer 2 is incorrect for the same reason, but a concomitant drop in systolic pressure also occurs because the left ventricle is delivering its stroke volume at considerably less resistance. Answer 4 is incorrect because the goal of antihypertensive drug therapy is to lower pressure, not slow pulse. Recognize the expected outcome initially a concurrent increase with treatment a concurrent decrease. When teaching a 3-year-old about a procedure, the nurse should realize that the most important factor influencing the child's ability to learn is: Chronological age. Developmental level. Present state of anxiety. Previous experience with illness and hospitalization. Anxiety is a significant factor; if it is too high, anxiety would negatively affect the child's ability to learn. Although the child's chronological age (Answer 1), developmental level (Answer 2), and previous experiences (Answer 4) are important for the nurse to assess in relation to the teaching style or techniques to be used, they are all less important in terms of the child's ability to learn. The question asks about influence on ability to learn, i.e., what affects learning, not when, (i.e., age-related timeframe. Choose the present over previous influences). What will the nurse encourage a patient who has had a modified right mastectomy to do as appropriate initial therapy 24 hours after surgery? Self-feeding and hair combing. Passive/active flexion and extension of the elbow and pronation and supination of the wrist. Abduction and external rotation of the right shoulder. Early ambulation and active extension and flexion of the elbow. The earliest exercises initiated are passive range of motion of the elbow, wrist, and hand; these exercises are begun on the first postoperative day. As the patient is able, she is encouraged to put those joints through active range of motion. These exercises assist in maintaining function and in reducing lymphedema. Progression to other exercises, such as hair combing and wall reaching, is dependent on wound healing, grafts, presence of drainage tubes, and the patient's tolerance. Answers 1, 3, and 4 are incorrect responses; they are implemented after a modified mastectomy, but are not appropriate initial therapy. When all are correct answers, consider the time period and patient limitations early postop. When teaching a young mother about a decrease in her milk production, the nurse should: Recommend weaning the baby onto formula. Assess the mother's feelings about breastfeeding. Refer the mother to La Leche League. Suggest supplemental feedings of glucose water. Any recommendation must be based on an assessment of the mother. This will ensure that her needs are met at an appropriate level and may prevent unnecessary stress and feelings of guilt at a later time. Answer 1 is incorrect. It maybe appropriate if she thinks she would rather wean or if the combination of breastfeeding and supplemental feeding proves inadequate for the infant or mother. Answer 3 is incorrect. It may be appropriate if the mother has experienced a similar situation; however, this referral should be initiated only after assessing and validating the need and appropriateness with the patient and with the La Leche League. Answer 4 is incorrect. It may be appropriate after assessing the mother's feelings about breastfeeding; however, the supplemental feedings will need to be validated with a physician, and they will probably consist of some type of formula rather than glucose water. Assess before "recommend," "refer," or "suggest." The last two options are OK, but a matter of timing (i.e., OK after). Besides enhancing pacemaker automaticity and facilitating AV conduction during heart block, what other effect of isoproterenol (Isuprel) would the nurse look for? Increased peripheral vascular resistance. Decreased automaticity of Purkinje fibers. Decreased bronchoconstriction. Decreased oral secretion. Actions of isoproterenol include relaxation (dilation) of smooth muscles in the bronchi, skeletal muscle vasculature, and alimentary tract, and thus decreased bronchoconstriction. Answer 1 is incorrect: increased peripheral vascular resistance is the action of norepinephrine (Levophed) or metariminol (Aramine). Answer 2 is incorrect: decreased automaticity of Purkinje fibers is the action of digoxin. Answer 4 is incorrect: decreased oral secretion is the anticholinergic effect of a drug such as atropine. Know the expected effects of cardiac drugs on the heart and lungs.. A pregnant woman at 29 weeks of gestation is concerned about her weight gain of 15 pounds during this pregnancy. The nurse will most likely determine that this woman is primarily concerned about: The baby's nutrition status. Her own body image. Her need to diet. Her need to gain more weight. Throughout pregnancy, especially after the second trimester, most women express anxiety over their change in body image. The nurse must be aware of the need to provide positive reinforcement and encouragement in order to facilitate and maintain the woman's self-esteem. Answer 1 is incorrect because during this stage of pregnancy the mother is very self-focused. Answer 3 is incorrect because most women realize that dieting during pregnancy is contraindicated unless prescribed by a physician. Answer 4 is of no concern to the pregnant woman because she is gaining plenty of weight. Choose the psychosocial answer. Choose the answer that is different from the others (not nutrition, diet, or weight). A patient who has had a myocardial infarction states, "I can hardly get my breath." Vital signs are BP 100/70, apical pulse 126, respirations 26. Pulmonary crackles and wheezes are heard halfway up the chest. The first nursing action is to: Administer morphine sulfate to allay the patient's apprehension. Assist the patient to a sitting position and lower the legs. Remove excess pulmonary secretions with suction. Administer oxygen at 10 liters, per mask instead of nasal catheter. While summoning the physician, the nurse should ensure that the patient's head is elevated. A sitting position bent slightly forward is best (a bedside table with pillows can be used for the patient to rest on), because it allows for the greatest lung expansion and gravity aids in shifting fluids toward the base of the lungs. Lowering the legs tends to decrease venous return by pooling blood in the periphery. Answer 1 is incorrect because morphine S04 may be given only per physician order. Answer 3 is incorrect because suctioning at this time is not indicated. Answer 4 is incorrect: supplemental oxygen may be given while awaiting medical orders, but initial nursing actions should be directed toward decreasing venous return and improving ventilation. First priority: make the patient comfortable or safe. When a woman is in labor, which action requested by the nurse could cause a problem to the woman? Empty her bladder. Lie on her back to facilitate adequate ventilation. Not bear down until she enters the second stage. Breathe slowly and evenly. The woman in labor is instructed to lie on her side to promote relaxation, to prevent supine hypotension, and to facilitate anterior rotation of the fetal head. Therefore, to tell the woman to lie on her back would cause a problem to the woman. Answer 1 is an appropriate action. A full bladder may impede progress or result in trauma to the bladder. Answer 3 is an appropriate action. Bearing down before the second stage is fruitless and serves only to expend energy and possibly damage the cervical opening. Answer 4 is an appropriate action. Slow, even breathing promotes adequate ventilation for the maternal and fetal systems and lessens anxiety. In positioning a patient, decide what you are trying to prevent or promote. The question is asking the position that is contraindicated. Review venal caval syndrome and prevention by position changes. A husband blames his wife for their son's problems with substance abuse, saying, "I always knew you were too easy on him. You see what giving him his way has done!" In understanding the father's response, the nurse should realize that this behavior indicates a nursing diagnosis of defensive coping as evidenced by: Guilt. Sublimation. Projection. Displacement. He is essentially blaming the situation on his son's mother because he is unable to cope effectively with his own feelings at this time. Answer 1 is incorrect because it is usually not a coping mechanism because it does not help a person cope with anxiety or other feelings. Answer 2 is incorrect because sublimation involves re-channeling a destructive or instinctual impulse that is socially unaccept able into an acceptable outlet, such as channeling anger into sports. Answer 3 is incorrect because it involves denying one's own thought or emotion and seeing that thought or emotion in others. Eliminate "guilt," because it is not a coping mechanism. Next, by definition, select the correct term. The doctor orders Burow's solution soaks for a toddler with eczema. In order to gain the toddler's cooperation with this treatment, the nurse should tell the toddler: Let's do this real fast and then you can see mommy and daddy. You don't want to have to stay here forever, do you? Let's make you all better now! This medicine will help you get better so you can go home. Help me pour some on your arms. This is magic medicine that will make all your boo-boos go away. Don't you want to chase away those boo-boos? To best gain the cooperation of a toddler, the nurse should help her or him focus on how the treatment will help the toddler go home; the nurse should also use distraction. Answers 1, 2, and 4 are incorrect because the nurse should never bribe, threaten, or lie to the child. Choose the one option that is not manipulative, frightening, or fantasy. When teaching parents how to provide CPR for their infant, it is important to stress: Applying systematic pressure to the chest with the heel of the hand. Compressing the chest at a rate of 100 compressions per minute. Placing the resuscitator's mouth over the infant's mouth to ensure an adequate seal. Blowing forcefully into the infant's air passages to fully inflate the lungs. The rate for cardiac compressions for infants is 100 per minute. Answer 1 is incorrect because pressure should be evenly applied with the fingers over the middle third of the sternum, not with the heel of the hand. Answer 3 is incorrect because to form a seal, the resuscitator should place his or her mouth over the mouth and nose of the infant. Answer 4 is incorrect because once the seal over the airway is made, the rescuer need only use gentle, not forceful puffs of air to inflate lungs. Visualize the procedure; omit incorrect steps; choose the one option that is different (option with a number100/minute) When planning to teach a client about the side effects of amphetamines, the nurse should emphasize that: Withdrawal from these drugs usually causes death. The body develops a tolerance to these drugs. An overdose of these drugs induces sleepiness. Physiological dependence may develop. There is no physiological dependence, but the person has to increase the dose to receive the same effect because the body develops a tolerance. Answer 1 is incorrect because withdrawal usually leads to severe exhaustion. Answer 3 is incorrect because overdoses induce hyperactivity within the system. Answer 4 is incorrect because psychological, not physiological, dependence develops from increased tolerance. Know side effects of amphetamines. While preparing a patient's preoperative medication, the nurse notes that the atropine S04 on hand is in a strength of 0.6 mg/mL. The prescribed dosage is 0.4 mg. The correct amount of atropine to administer is: 1.5 ml. 1 mL. 10 minims. 8 minims. Correct medication administration is extremely important. When the medication order is of a different strength from the supplies at hand, using the following formula will be helpful in determining the correct dose: <br><u>Desired</u> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;_{X &nbsp;&nbsp;&nbsp;&nbsp;}Quantity ₌ <u>0.4</u> &nbsp;&nbsp;_{X &nbsp;&nbsp;}<u>15 minims</u><br />Available&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; on hand&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 0.6&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1<br />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp; ₌ <u>2</u>&nbsp;&nbsp; _{X &nbsp;&nbsp;}<u>15</u><br />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ₌ <u>30</u><br />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;3<br />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ₌ 10 minims</p><br> <br> Answers 1, 2, and 4 are inaccurate calculations. Know the correct ratio formula. If a pregnant woman remains essentially healthy, the nurse's health teaching about safeguards to maintain throughout pregnancy should be for her to: Stop working by week 32 of gestation. Avoid intercourse. Avoid alcohol and smoking. Eat a minimum of three full meals each day. Alcohol and smoking are thought to present dangers to the fetus. Answer 1 is incorrect: many women do work until they are about to give birth. Answer 2 is incorrect because intercourse is permissible in the absence of vaginal bleeding. Answer 4 is incorrect because caloric requirements for growth must be maintained. Select the option that deals with risk factors. Given a diagnosis of pulmonary edema, the nurse knows that a patient's dyspnea is the result of: Increased lung compliance due to mechanical congestion. Decreased C02 retention. Decreased venous return. Fluid shift from systemic circulation to lungs. The patient's dyspnea is due to a shift of fluid from systemic circulation to lungs. With left ventricular failure, blood backs up in the pulmonary vasculature, causing increased pulmonary pressure and exudation of fluids into the interstitial space, alveoli, and bronchiolesthat is, pulmonary edema. Answer 1 is incorrect because the mechanical congestion of the lungs decreases expandability (compliance) and increases the work of breathing; that is, the patient becomes aware of his or her efforts at breathing (dyspnea). Answer 2 is incorrect because pulmonary edema also decreases the amount of pulmonary membrane available for the diffusion of gases, thereby decreasing arterial oxygen and increasing the likelihood of C02 retention. Answer 3 is incorrect because venous return is increased, not decreased. Look for similar words in the stem and answer (e.g., "pulmonary" and "lung"; "edema" and "fluid"). The nurse realizes that the discharge of green amniotic fluid may indicate: Rh or ABO incompatibility. Fetal distress occurred approximately 36 hours ago. Recent or current hypoxia. An Abruptio placenta has occurred. Green fluid is usually seen when the fetus is or has recently been in distress and hypoxic. Answer 1 is incorrect because Rh or ABO incompatibility may result in a yellow fluid. Answer 2 is incorrect because fetal distress that occurred 36 hours ago also may result in a yellow fluid. Answer 4 is incorrect because abruptio placentae usually results in a port wine-colored fluid. The key word is green. Recall normal appearance of amniotic fluid. Recall what alteration in color (e.g., green, yellow, or port wine) is matched with what problem. Also time element is important: in fetal distress, green is now and yellow was before (36 hours ago). The rationale for using humidified oxygen with tracheal tubes is that: It is a traditional procedure. It is a means of providing fluid intake. It decreases insensible water loss. The natural humidifying pathway has been bypassed. The natural pathway of humidification, the upper respiratory tract, has been bypassed. Therefore, to prevent drying out of the mucous membranes of the bronchi, as well as crusting of secretions, humidification by nebulization is provided. Answer 1 is incorrect: although supplying humidification during oxygen therapy has become standard, it is not a rationale for its use. Answers 2 and 3 are incorrect because they are not specific to this question, though probably true to some extent. Identify the key concept humidification. Parents of a 6-month-old infant bring the baby in for a physical examination; all immunizations are up-to-date. This infant should receive three of the following immunizations at this time; which immunization should not be given? Hepatitis B. Diphtheria, tetanus, and pertussis (DTP). H. influenzae type b. Measles, mumps, rubella. Measles, mumps, and rubella are first given at 12-15 months, and repeated at either 4-6 years or 11-12 years. Hepatitis B (Answer 1), DTP (Answer 2), and H. influenzae type b (Answer 3) should all be given at 6 months. Knowing immunization schedule is the only way to select this answer. Note that the question asks which is not given. An IV rate is to be regulated to keep vein open (KVO). The nurse knows that the longest possible time that a single 1000 mL bottle or bag can infuse safely is: 24 hours. 5 hours. 18 hours. 12 hours. The likelihood of product contamination after opening the bottle or bag increases over time, but the bottle or bag can hang safely for a maximum of 24 hours. Bottles or bags used for intermittent IV medications should be timed and dated, and not left hanging at the bedside for over 24 hours. The use of the heparin lock has decreased the need for KVO IVs, and medications are administered with 50 mL or 100 mL single-use solution bags. Answers 2, 3, and 4 are incorrect because the times are all too soon and would unnecessarily increase the cost of hospitalization. The best answer includes all the other choices. The nurse should know that the best position to check an adolescent for scoliosis is: Standing up straight. Lying flat on the stomach. Standing and bending 90 degrees at the waist. Sitting in a straight-back chair. To effectively screen for the S-shaped lateral curvature of scoliosis, the nurse should ask the adolescent to stand and bend over at the waist 90 degrees. The nurse should look for unevenness of the shoulders or hips, or any curves or humps, which require further follow-up and evaluation. Answers 1, 2, and 4 are incorrect because no other position is recommended. Select the position that is not like the others; three describe a straight or flat position, only one involves bending. A unit of blood is ordered for a patient when the BP drops to 90/60. What is the most important safeguard before administering blood? Refrigerate unit of blood until immediately before giving. Agitate the blood so it is well mixed. Carefully check labeled blood against patient's wristband. Infuse the blood through a blood warmer. Some of the most serious reactions occurring with blood transfusions are the result of human error. To reduce human error, it is essential for two nurses to verify that the patient's name and hospital number on the blood bag correspond exactly to that on the wristband. Answers 1, 2, and 4 are incorrect because although they are proper safeguards, they are not the first priority. Only one choice deals with direct patient safety. Potassium chloride is to be added to an infant's intravenous fluids. Before adding this electrolyte, the nurse should determine that: The infant has voided recently. Moro reflex is present. Respiratory rate is between 25 and 40. Mucous membranes are moist. Before adding potassium chloride to any IV line, the nurse must check that the patient's kidneys are functioning to avoid potassium overload and hyperkalemia. Answers 2, 3, and 4 are incorrect because it is not necessary to check reflexes, respiratory rate, or mucous membranes before adding potassium to the IV line. Remember, no pee = no potassium. A young woman describes experiencing a heavy vaginal discharge and severe itching for the past 3 days. She is diagnosed as having Trichomonas vaginalis infection. Health teaching for this woman should include dosage, administration, and signs and symptoms of side effects of which medication as treatment for this condition? Tetracycline. Erythromycin Nystatin. Metronidazole. Metronidazole (Flagyl) is the drug of choice in treating Trichomonas vaginitis. Answers 1 and 2 are incorrect because tetracycline and erythromycin are ineffective against Trichomonas infection and are more commonly used in treating bacterial disease. Answer 3 is incorrect because nystatin has little effect on Trichomonas vaginalis, but is the drug of choice for Candida infection. Choose the pharmacological agent commonly used for STDs and vaginal infections, rather than bacterial diseases (1 and 2). Immediately on returning to the recovery room, a patient's above-the-knee amputation stump should initially be: Elevated on a pillow to reduce occurrence of edema and hemorrhage. Placed in Buck's traction to prevent skin and muscle retraction. Firmly bandaged to a padded board to prevent contractures. Wrapped in an Ace bandage to reduce edema formation. To reduce bleeding and edema, the stump is elevated for the first 24 hours; after 24 hours, however, hip flexion contracture may occur with prolonged elevation. Answer 2 is incorrect because this procedure is not used for amputations. Answer 3 is incorrect because this procedure is used with a below-the-knee amputation, to prevent contractures in the knee joint. Answer 4 is incorrect: this is a standard postoperative procedure initiated by the surgeon in the operating room to facilitate shrinkage of the stump and to prevent edema. Look for independent nursing actions positioning. When a postop patient is admitted following an appendectomy, the first action the nurse should take is to: Attach nasogastric tube to suction. Calculate the IV flow rate and adjust the drip. Monitor vital signs. Check patient's ID band. When a nurse is admitting a new patient to the unit, the first action the nurse should take is to correctly identify the patient. If the patient is fully awake and alert, the nurse can ask the patient for his or her name; if the patient is a newly postop patient, still under the influence of anesthesia and medication, the nurse should first check the ID band. After identifying the patient, the nurse could then proceed to monitor vital signs (Answer 3), check the IV (Answer 2), and attach the Salem sump tube to suction (Answer 1). Focus on the patient, then the procedures with priority questions. Order of priority starts with a KIS (keep it simple) option (i.e., identify the patient). The nurse planning to administer a unit of blood to a child should know that after it is removed from the refrigerator, the blood should be transfused within: Six hours. Two hours. Four hours. One hour. Refrigerating blood assists in delaying the growth of bacteria. The blood must be administered within 4 hours, not 6 hours (Answer 1), but not so rapidly that the patient experiences overload (Answers 2,4). Eliminate the "extremes" first (too short, too long time periods). In observing women in the latent phase of the first stage of labor, the nurse would expect to see which behavior? Tendency to hyperventilate. Euphoria, excitement, and talkativeness. Fairly quiet and introverted behavior. Irritability and crying. Euphoria, excitement, and talkativeness are all seen initially, when the woman is fairly energetic and anxious to have labor begin. Answer 1 is incorrect because a tendency to hyperventilate usually occurs during the midactive phase. Introverted behavior (Answer 3) and irritability or crying (Answer 4) usually occur in the transitional or deceleration period of the active phase of the first stage. The key is a time element. First stage, first euphoria. Review phases and stages of labor and a woman's expected responses. To which postoperative complication is a patient who has had a modified mastectomy predisposed because of the nature of her surgery? Peripheral thrombophlebitis. Wound dehiscence. Atelectasis. Paralytic ileus. Splinting of the incision and tight pressure dressings tend to reduce lung expansion and ventilation. As a result, mucus can block off small bronchioles, causing atelectasis or collapse of distal alveoli. Answer 1 is incorrect because peripheral thrombophlebitis is always a threat if the patient's legs are not exercised. In most patients, early ambulation prevents its occurrence. Answer 2 is incorrect because wound dehiscence is more likely to occur with abdominal surgeries. Answer 4 is incorrect because paralytic ileus is more likely to occur with abdominal surgeries, though it may occur as the result of the effects of anesthesia on autonomic nervous system function, or hypokalemia. Visualize die patient and location of surgery. In teaching a couple about preparation for childbirth, the nurse should first: Evaluate the couple's knowledge base of childbirth techniques. Assess the couple's level of readiness to learn. Consult a childbirth nurse practitioner regarding what to tell the couple. Refer the couple to a Lamaze childbirth class. In evaluating the couple's present knowledge base of childbirth and childbirth techniques, the nurse will be able to set up a more efficient and effective program of learning for the couple. The couple may have already investigated resources and may need more validation than primary health teaching. Answer 2 is incorrect; a secondary goal would be to meet the couple at their level of readiness to ensure optimal learning. Answer 3 is incorrect: if unsure of the information, the nurse may consult with or refer to a specialist in the area. Answer 4 may be inappropriate if the couple desires an alternative method. First, evaluate what they know; then assess readiness to learn. Following surgery for a ruptured appendix, the nurse should place the patient in a semi-Fowler's position primarily to: Fully aerate the lungs. Promote drainage and prevent subdiaphragmatic abscesses. Splint the wound. Facilitate movement and reduce complications from immobility. Following surgery for a ruptured appendix, the patient should be placed in a semi-Fowler's position to promote drainage and to prevent possible complications, such as diaphragmatic abscess. Answer 1 is incorrect: this position will help aerate the patient's lungs by allowing for maximum expansion, but it is not the primary reason for this position. Answer 3 is incorrect because this position will not help splint the incision. Answer 4 is incorrect because this position will not help facilitate movement or necessarily reduce complications. Visualize the position and how it would affect the operative site. The nurse assessing a person who has a history of substance abuse would expect to find which characteristic? A very assertive individual. A very dependent individual. A very mature individual. A very aggressive individual. Drug abusers tend to be excessively dependent and passive, become easily frustrated, and cannot cope with anxiety. Answers 1, 3, and 4 are incorrect because assertive, mature, or aggressive individuals are generally able to externalize their feelings and fears or to cope effectively with stress. Choose the option that is different (dependent vs. outgoing). The earliest signs of whole blood transfusion reaction a nurse would monitor for are: Headache and elevated temperature. Hypertension and flushing. Urticaria and wheezing. Oliguria and jaundice. The earliest indications of blood transfusion reactions are headache, chills, and elevation of temperature. The skin may also become pale and cool, and hypotension may develop quickly Respirations generally increase in rate and depth. Should symptoms occur, stop transfusion, notify physician, and send a stat urine specimen to the lab for analysis. Answer 2 is incorrect: hypertension and flushing are not indicators of a transfusion reaction. Answer 3 is incorrect: wheezing and urticaria may occur, but are not the earliest indications of blood transfusion reaction. Answer 4 is incorrect because oliguria and jaundice are late signs of transfusion reaction, secondary to hemolysis of red blood cells. Think timing. Stem asks for earliest signs. The nurse caring for a patient recovering from GI bleeding should: Plan care so the patient can receive at least 8 hours of uninterrupted sleep each night. Monitor vital signs every 2 hours. Make sure that the patient takes food and medications at prescribed intervals. Provide milk every 23 hours. Food and drug therapy will prevent the accumulation of hydrochloric acid or will neutralize and buffer the acid that does accumulate. Answer 1 is incorrect because 8 hours would be too long without food/medication. Answer 2 is incorrect because monitoring vital signs every 2 hours is not indicated unless bleeding or shock continues, and if those symptoms are present, vital signs should be taken more frequently. Answer 4 is incorrect: milk is not a food of choice because it increases gastric acid production. Key word: recovering. Action should promote healing. To monitor a patient's fluid volumes more closely, a CVP line has been inserted via the right subclavian vein. The nurse needs to know that CVP assesses the pressure in: The left atrium. The right atrium. The left ventricle. The right ventricle. Central venous pressure (CVP) is a reflection of pressures in the right atrium and systemic veins. Although CVP is the least sensitive indicator of left ventricular end-diastolic pressures (increased with decreased ventricular compliance due to myocardial infarction and left ventricular failure), the CVP line is a safer one than a pulmonary artery (PA) line. In addition, it can be used to estimate blood volumes, obtain venous blood samples, and administer fluids. Answer 1 is incorrect because a PA line reflects left atrial pressure. Answer 3 is incorrect because a PA line indirectly reflects left ventricular pressure. Answer 4 is incorrect because right ventricular pressure is not measured by a CVP line. Visualize the chambers of the heart. The CVP catheter tip "sits" at the entrance. A patient is diagnosed as being mildly hypertensive. In assessing this patient's BP, the nurse most likely finds that the resting diastolic pressure is: Between 110 and 120 mm Hg. Between 90 and 100 mm Hg Between 120 and 140 mm Hg. Between 100 and 115 mm Hg. The patient with mild hypertension usually has a diastolic pressure of between 90 and 100 mm Hg. Answer 1 is incorrect because diastolic pressures of 110-120 mm Hg are considered moderately hypertensive. Answer 3 is incorrect because diastolic pressures of 120-140 mm Hg are considered severely hypertensive. Answer 4 is incorrect because diastolic pressures of 100-115 cross over two levels of hypertension; persons with these diastolic pressures would probably be considered to have mild to moderate hypertension. Know normal values: "mild" would be something just at or above 90 mm Hg. A patient has had a permanent pacemaker inserted, with the pacing catheter introduced into the right external jugular vein and positioned in the right ventricle. Which nursing care activity is the nurse's first priority in the early postimplantation period? Restricting activity to prevent pacing catheter displacement. Monitoring the ECG continually, noting rhythm, rate, appearance, and amplitude of pacing spike. Implementing passive range-of-motion exercise to the right arm to prevent "frozen shoulder." Maintaining sterile dressings over the operative site to prevent infection. Each of these activities (restricting activity, monitoring ECG, implementing passive range of motion, maintaining sterile dressings) is a priority in the early postinsertion period. However, because a transvenous approach was used with this patient, it is essential that activities be restricted for the first few days to reduce the risk of catheter dislodgement. To monitor for this complication, periodic comparisons of the patient's current rhythm strip should be made with the tracing taken at the time of insertion. Changes in either the pacemaker artifact or pacemaker-initiated QRS indicate a change in position. Although this may not always be significant, it becomes so if the pacemaker fails to capture, causing a decrease in heart rate and cardiac output. Answers 2, 3, and 4 are incorrect because restricting activity is the nurse's first priority. When all answers are correct, look for the most important at that point. A client takes secobarbital (Seconal) whenever feeling "too stressed," such as whenever there is an exam or whenever the client feels too pressured, which happens at least four or five times a week. The nurse should be aware that large doses of secobarbital can cause: Tachycardia. Hypertension. Assaultive behavior. Increased respirations. With large dosages of secobarbital there maybe an increase in anger or a deep sleep, depending on the individual's reaction. Secobarbital, a barbiturate, causes a depression of the CNS, so its effects usually include bradycardia (not tachycardia, Answer 1), hypotension (not hypertension, Answer 2), and depressed respiration (not increased respirations, Answer 4). Look at the pattern of responses and choose the one that is different (in this case, the psychosocial answer). The nurse knows that angina pectoris, which occurs after eating, may be due to: Incomplete digestion of fats due to a decrease in pancreatic enzyme, thereby increasing reflux. Local blood flow regulators that shunt blood to gut during digestion, thereby decreasing coronary artery perfusion pressures. Abdominal distention from swallowing air during eating, thereby decreasing diaphragmatic excursion and arterial Po2. Decreased heart rate and blood pressure, resulting in increased myocardial oxygen consumption. Blood flow to the intestines is increased following ingestion of meals, to facilitate digestion and absorption. As a result of this circulatory shift, other organs receive less volume. This blood shift is partially responsible for feelings of sleepiness and lethargy following large meals. If a patient has a large atheromatous plaque in one of the coronary arteries, the decreased pressure and flow of blood may result in transient ischemia. Answer 1 is incorrect because decreased pancreatic enzyme secretion results in diarrhea and steatorrhea (large amounts of fats in the stools). Answer 3 is incorrect: swallowing air during eating can produce an uncomfortable feeling of fullness that can be relieved by eructation (belching), but should not decrease arterial oxygenation. Answer 4 is incorrect because a decrease in heart rate and blood pressure will decrease rather than increase myocardial oxygen consumption. Read the choices and look for clues: the correct answer mentions "digestion" and "coronary" perfusion. A toddler is diagnosed as having iron deficiency anemia. In addition to teaching the parents to give this toddler Fer-In-Sol (ferrous sulfate) between meals, the nurse should also instruct them to give this medication with: Orange juice. Milk. Apple juice. Prune juice. Liquid iron preparations such as Fer-In-Sol should be given with a citrus juice to enhance the absorption of the iron. Answer 2 is incorrect because it may actually block the absorption of iron. Answer 3 is incorrect because apple juice will not enhance the absorption of iron. Answer 4 is incorrect because prune juice will not enhance the absorption of iron (however, iron does cause constipation, and prune juice may be given to treat or prevent this side effect). Concept: absorption is needed. The best source of vitamin C is needed to accomplish this. The nurse knows that the desired effects of morphine SO4, and atropine S04 have been achieved preoperatively when: Pain is relieved and anxiety is reduced. Secretions are decreased and sensitivity to stimuli is reduced. Sleep occurs and oral secretions are reduced. Sensitivity to pain is reduced and muscular relaxation occurs. The desired effect of morphine in this situation is to reduce sensitivity to stimuli in order to allay apprehension and, in some cases, to induce drowsiness. Atropine acts to dry oral and bronchial secretions, reducing the hazards of aspirations during anesthetic induction. Answer 1 is incorrect because although morphine effectively relieves pain, pain relief is usually not an objective in administering a preoperative medication. Answer 3 is incorrect because drowsiness, not sleep, may result. Answer 4 is incorrect because morphine is not a muscle relaxant. Know the desired and expected outcomes. A woman in labor has a history of undiagnosed vaginal bleeding. Which procedure may be contraindicated on her arrival in the labor room? Initiating intravenous therapy. Taking her blood pressure. Examining her vaginal canal. Monitoring FHR. Examining her vaginal canal is contraindicated initially because of her preadmission history of bleeding. Answer 1 is incorrect: initiating IV therapy is imperative to have a line available for any ordered medications or fluids. Answers 2 and 4 are incorrect because taking her blood pressure and monitoring FHR are essential to establish baseline data and to monitor the mother's and infant's status. The problem may be placenta previa or other bleeding abnormalities in pregnancy. Choose the answer that covers what the nurse would not do when the question asks for a procedure that is contraindicated. The problem is vaginal bleeding, so select the option that relates to the vaginal canal?. The mother of a child with eczema asks the nurse if she can bathe the child in the bathtub at home. The best response by the nurse would be: It would probably be a good idea to check with your doctor first. Perhaps in a week to 10 days you can begin tub baths; until then, a sponge bath will be adequate. No, baths are not generally permitted for children with eczema. Yes, frequent baths will help dry the lesions. Frequent baths will help lesions crust over, dry, and heal; thus bathing more frequently than usual is recommended. Baths will also reduce the bacterial count, thus reducing the risk of infection. However, no soap should be used, because it will cause excessive drying and cracking of both the affected areas and the healthy skin. Answer 1 is incorrect because it is inappropriate for the nurse to tell the mother to check with the doctor first. The nurse can and should handle this question, because teaching is part of the nurse's responsibility. Answer 2 is incorrect because it would be incorrect for the nurse to advise the mother that sponge baths are recommended for 10 days. Answer 3 is incorrect because it would be incorrect for the nurse to advise the mother that baths are not permitted. When in doubt, focus on two options that are opposites ("no" vs. "yes"). Eliminate "doctor" and "perhaps" options. Crepitus in the neck and upper chest of a patient who has a new tracheostomy in place is caused by: Air from a displaced tracheal tube. An inadequately inflated tracheostomy cuff. An overinflated tracheostomy cuff. Edema from the trauma of surgery. Crepitus in the neck or upper chest is a sign that the tracheal tube is no longer in place and is delivering oxygen into the interstitial or mediastinal space. This condition may severely impair ventilation of the lungs. Answer 2 is incorrect because an inadequately inflated cuff creates an air leak around the tracheal tube. Answer 3 is incorrect because an overinflated cuff can cause necrosis of the trachea. Answer 4 is incorrect because edema is characterized by fluid, not air, in the tissues. Use a process of elimination. With 2 choices, make a mental picture: would air or fluid make a noise. An expectant couple is concerned about what effect preeclampsia may have on the fetus. Which indicator or test of fetal well-being should the nurse teach the couple to expect most commonly during the rest of the prenatal period? Nonstress test. Amniocentesis. L/S ratio. Fetal blood gases. The procedure most commonly used in assessing fetal well-being is the nonstress test, which provides valuable data without inducing hazard to mother or fetus. Answer 2 is incorrect because amniocentesis is used selectively, that is, in cases where the information gained is vital to fetal survival. Answer 3 is incorrect because the lecithin-sphingomyelin (L/S) ratio is an indicator of fetal lung maturity; it would require amniocentesis. Answer 4 is incorrect because determination of fetal blood gases is not a common procedure and is most often done on scalp blood when the mother is in labor. The key words are "most common." Answers 2 and 3 involve the same procedure, amniocentesis, which can be hazardous and is not commonly used; neither is determination of fetal blood gases (4) The nursing aide caring for a child in Bryant's traction reports that the child's buttocks are resting on the mattress. The nurse would be most correct in telling the aide that: This is where the buttocks should be. The buttocks should be slightly off the mattress. This is the responsibility of the nurse. The child will need special skin care to avoid pressure areas or breakdown. In Bryant's traction, the hips and buttocks should be raised slightly (1 inch) above the mattress, not resting on the mattress (Answer 1), for the traction to be effective. Answer 3 is incorrect because although the nurse is ultimately responsible, the aide should be commended for having brought this concern to the nurse's attention. Answer 4 is incorrect: although it is true that this child will need special skin care due to prolonged immobility, the nurse should first take measures to correct the problem with the traction. Remember that weights and pulleys must hang free and clear for traction to be most effective. Which nursing intervention for a patient with a Hemovac is inappropriate? Observing and recording the amount and color of the drainage. Maintaining suction by emptying and recompressing the apparatus regularly. Increasing suction by attaching the Hemovac to wall suction as the drainage increases. Preventing traction on the drainage tubes by repositioning the Hemovac each time the patient is repositioned. The Hemovac is a portable suction system that provides low negative pressure (30-45 mm Hg) to gently remove excess fluid and debris from the wound. It does not require attachment to any other suction system. Answers 1, 2, and 4 are incorrect because they are standard and appropriate nursing measures. Look for an incorrect nursing action. An adolescent boy was admitted for substance abuse and hallucinations. This client's mother asks the nurse to talk with her son's father when he arrives at the hospital. She says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to: Inform the mother that she and the father can work through this problem themselves. Refer the mother to the hospital social worker. Agree to talk with the mother and the father together. Suggest that the father and son work things out. By agreeing to talk with both parents, the nurse can provide emotional support and further assess and validate the family's needs. Answer 1 is incorrect because it lacks empathy and makes the mother feel rejected. Answer 2 is incorrect: it may be an appropriate action after doing further assessment. Answer 4 is incorrect because this suggestion should be made only if, after further assessment and discussion with the physician and social worker, the health team thinks it is appropriate. However, at this time it is inappropriate. Providing support and maintaining a family focus is the best answer. Following an amputation, a nursing measure to help reduce the size of the stump once the surgical wound is healed is: Elevation of the stump on a pillow when reclining. Pushing the stump against a hard surface. Wrapping moist, warm soaks on the thigh. Applying an elastic bandage. After the stump has healed, an elastic bandage is applied to it to produce shrinkage and a conical shape. It is a compression dressing, with maximal compression at the distal end of the stump and minimal compression at the proximal end. The stump is wrapped with a clean bandage each day and rewrapped four times each day to maintain compression. Answer 1 is incorrect: elevation of the stump after the first 24 hours is always contraindicated because of the risk of flexion contracture in the hip. Answer 2 is incorrect: pushing the stump against a hard surface will facilitate toughening the skin for weight bearing once the prosthesis is applied, but it does not facilitate either reduction in size or shaping of the stump. Answer 3 is incorrect: warm, moist soaks may be applied to reduce phantom pain discomfort, but they are not applicable to this situation. Visualize the effect of each action on stump size? The nurse would interpret a patient's central venous pressure (CVP) as normal if the pressure were: 4-10 cm H2O. 20-30 mm Hg. 10-20 cm H20. 7-14 mm Hg. Central venous pressures of 4-10 cm H2O are normal. Some clinicians consider up to 15 cm H20 to be normal, but pressures over 15 cm H20 (Answer 3) clearly indicate hypervolemia or heart failure. Answers 2 and 4 are incorrect because CVP is measured by water, not mercury. Know normal ranges to interpret changes. The nurse working with a family that is using an apnea monitor should know that the monitor's most problematic side effect is: Sounding the alarm whenever the infant moves around in the crib. Overprotectiveness by the parents. Developmental lag in the infant. Unreliability of the monitor. Many parents become "slaves" to the monitor and become overprotective to the infant. Answer 1 is incorrect because faulty alarms should only occur if the electrodes are not properly placed. Answer 3 is incorrect: the monitor should have very little effect on the infant's developmental level, provided it is used appropriately and the infant is environmentally stimulated. Answer 4 is incorrect because most apnea monitors are reliable if properly used. Picture what probably happens when the alarm sounds. The parents get alarmed and tend to "hover." Note the use of the words problematic side effect in this question. During an adolescent's hospitalization for treatment of substance abuse, the nurse must be able to handle a variety of behavior problems. In implementing care for this client, which action would be the least appropriate? Allowing the client to select some of the food he or she wants to eat. Restricting activity level. Encouraging friends to visit. Closely monitoring behavior. Encouraging friends to visit is inappropriate because they may bring drugs or encourage the client to act out by leaving the hospital or taking drugs. Visitation should not be completely curtailed but should be closely monitored. Answer 1 allows the client to feel that he or she has some control over care, which is especially important during adolescence. Answer 2 helps the client regain strength and decreases stimuli in the immediate environment. Answer 4 allows the nurse to monitor care more closely. Key phrase: "least appropriate." The nurse knows that after administration of nitroglycerin, a patient's angina will be relieved because the drug: Constricts cardiac chambers to reduce workload. Stimulates the heart rate to increase blood supply to the myocardium. Increases myocardial contractility. Decreases workload of the heart through lowering the systemic blood pressure. Nitroglycerin causes vasodilation and a decrease in systemic blood pressure, which subsequently decreases the amount of work the heart must perform. Answer 1 is incorrect because constriction of the cardiac chambers would increase cardiac resistance and workload. Answer 2 is incorrect because nitroglycerin does not increase heart rate. That effect would be seen with isoproterenol (Isuprel) or atropine. Answer 3 is incorrect because to increase myocardial contractility, digoxin would be given. Look for an effect of vasodilation (e.g., decreased pressure). A patient is hospitalized with a BP of 170/100, difficulty breathing, dizziness, and weakness. The nurse establishing this patient's care should consider: Ensuring that a different nurse takes care of the patient each day to prevent hospital fatigue. Planning care to allow for periods of activity. Identifying any misconceptions the patient may have regarding hypertension. Instructing the patient to report only major symptoms to the physician. Understanding the condition will increase the patient's compliance with the treatment regimen. Answer 1 is incorrect because it is important to provide consistency in assigning nurses to care for the person with hypertension, to minimize stress and provide constant and consistent reinforcement of care and health teaching. Answer 2 is incorrect: the nurse should plan care to reduce the number of situations that create or increase physical stress. Answer 4 is incorrect because the patient must report minor symptoms as well as major ones. Do not pass the buck to the MD. Think immediate need. In planning for discharge, the nurse should inform a patient who has had a right modified mastectomy of actions that may increase lymphedema. Which activity is most likely to increase symptoms? Wearing gloves for household tasks or gardening. Carrying heavy groceries in her right arm. Wearing dresses with elasticized sleeves. Driving to and from work. Carrying anything heavy, such as groceries or even a purse, on the affected side may increase the occurrence of lymphedema. Answer 1 is incorrect because wearing gloves for household tasks or gardening is encouraged to prevent lymphedema or possible infection if the skin is broken. Answer 3 is incorrect because elasticized sleeves may be worn if they are not tight. However, any constricting garment or jewelry should be avoided. Answer 4 is incorrect because driving, particularly if the affected arm is kept high on the steering wheel, should not increase lymphedema. Do not read any additional facts into the choices. The stem does not say tight. A woman is in preterm labor and is bleeding. She requests a sip of water after being in labor for 2 hours in the hospital. The most appropriate nursing action would be: Checking the physician's orders. Giving her a small sip of water. Offering her ice chips. Telling her she cannot have fluids at this time. Fluid orders vary among hospitals, physicians, and childbirth methods. Because the woman is in preterm labor and is bleeding, the orders will probably maintain her NPO with an IV. Answers 2 and 3 are incorrect because giving her a small sip of water or ice chips may be contraindicated at this time. Answer 4 is incorrect because the physician may allow sips of water or ice chips. Look at the verbs: "check" with the MD, "give," "offer," "tell... cannot have." Two options give the water; one option withholds it. The best answer is to check with the MD because this is a complicated labor. A mother states that the pediatrician told her that her son has numerous allergies, including milk allergies. The nurse should offer him which formula? Lofenalac. Lonalac. Similac with iron. Isomil. Infants or children with milk allergies should be offered a lactose-free formula such as Isomil. Answers 1, 2, and 3 are incorrect because these formulas are lactose based and are contraindicated for infants or children with milk allergies. Know which formulas are lactose free: Isomil, Prosobee, and Nutramigen. What would receive the least emphasis in the nurse's pre-discharge education plan for a patient who has had a permanent pacemaker inserted? Rationale for pacemaker implantation. Pacemaker function and signs indicating malfunction. Therapeutic program, including medication, diet, activity schedule, and safety precautions. Necessity for periodic follow-up visits to physician. The rationale for pacemaker implantation is presented in the preinsertion period and is reinforced in the postinsertion period and therefore receives the least emphasis in the pre-discharge plan. Answers 2, 3, and 4 are incorrect: they are essential components of a pre-discharge teaching plan, because the patient must focus on management of the pacemaker, and they all receive great emphasis. Look for a pattern. The least emphasis would be on a preinsertion education topic. The nurse needs to know that SIDS usually occurs: Within 2-4 weeks after birth. Between 2 and 4 months after birth. More than 6 months after birth. Between 6 and 9 months after birth. SIDS usually occurs within the first year of life. The peak time appears to be between 2 and 4 months after birth. Answer 1 is incorrect because SIDS rarely occurs before 4 weeks after birth. Answers 3 and 4 are incorrect because SIDS is comparatively unusual after 6 months of age; 95% of all cases occur by 6 months of age. Answers 3 and 4 arc virtually the same; therefore, neither choice is the correct answer. A patient's vital signs are BP 124/84, apical pulse 100 and regular, respirations 24. Given that this patient's normal BP is 144/96 and average pulse is 80, the nurse concludes that the present vital signs are related to: Increased vagal stimulation of SA node. Arrhythmias. Cardiogenic shock. Sympathetic nervous system response. Baroreceptors in the carotid sinus and aortic arch constantly monitor and respond to variations in blood pressure. Decreased cardiac output results in a drop in blood pressure. These receptors transmit afferent signals to the cardiovascular center in the medulla. Activation of these centers results in increased vasoconstriction, heart rate, and force of cardiac contraction via adrenergic efferents in the sympathetic nervous system. Answer 1 is incorrect because vagal stimulation of the SA node decreases heart rate. Answer 2 is incorrect because arrhythmias generally produce an irregularity in heart rhythm. Answer 3 is incorrect because these vital signs do not indicate shock at this time. Know the differences between sympathetic and parasympathetic responses. The nurse must recognize the side effects of morphine and atropine administration given preoperatively, which include: Bradycardia, anorexia, and decreased urine output. Hypertension, nausea, vomiting, tachycardia. Hypotension, cotton mouth, nausea, and vomiting. Dryness, cotton mouth, constricted pupils, and bradycardia. Morphine sulfate acts not only to reduce pain and anxiety by blocking the activity of the reticular substance in the brainstem, but also to relax vascular smooth muscle, thereby decreasing blood pressure. Nausea and vomiting are common adverse side effects of this medication. Atropine is an anticholinergic whose drying effects tend to cause the patient to complain that the mouth feels like cotton. Answers 1 and 4 are incorrect because atropine also blocks vagal effects on the heart, increasing pulse rate, not decreasing it. Answer 2 is incorrect because blood pressure is decreased, not increased. Look for side effects that relate to the drug action: vasodilation (morphine) and decreased secretions (atropine). In planning discharge care for a patient after treatment for hypertension, the nurse should emphasize: Medication scheduling and side effects. Need to change jobs. Importance of smoking less. Sexual activity restrictions. Teaching regarding medications is essential if the patient is going to recognize side effects. The patient must be told that medications must continue even though he or she "feels" fine. Answer 2 is incorrect because changing jobs is unrealistic in most cases. The patient should be taught stress-reduction or relaxation techniques to better handle work-related stress. Answer 3 is incorrect because the patient should quit smoking, not just lessen the amount. Answer 4 is incorrect because there are generally no limitations on sexual activities merely due to hypertension; unless restrictions are warranted because of an individual's specific condition, this is considered irrelevant when teaching the average hypertensive patient. Look for a pattern: only one choice emphasizes treatment. The MD orders an IV of D,W at 40 mL/hr. A 500 mL bag, with a pediatric microdrip chamber, is hung at 11:00 a.m. At 3:15 p.m., the nurse notes that the bag has 100 mL left. What should be the nurse's initial action? Readjust the flow rate to 40 microdrops per minute. Hang a new 500 mL bag of fluid. Maintain the flow rate at 20 microdrops per minute until the IV is back on schedule. Notify the physician. If the IV infused at the correct rate of 40 mL/hr from 11:00 a.m. to 3:15 p.m., the patient should have received 170 mL of IV fluid; because the patient has received twice the prescribed amount, the nurse should first correct the rate, then notify the physician (Answer 4). (The nurse should also check at this time to see if the IV line is being affected by the position of the limb.) If, after contacting the physician, a new rate is ordered, only then would the nurse adjust the rate to a level lower than originally prescribed (Answer 3). Answer 2 is incorrect because there is no reason to hang a new bag at this time. First, decide whether this is OK or not OK. Next, choose a corrective action before calling the MD. Look for a choice that first addresses the patient's safety? The nurse knows that the primary advantage of Hemovac wound suction is that it: Exerts high, even suction. Allows easy mobility because it is lightweight. Speeds wound healing by removing excess fluids. Reduces the occurrence of postoperative infection. The primary advantage of Hemovac suction is that it removes excess fluid and debris from the wound site that could retard tissue granulation and healing. If serum is allowed to accumulate under the skin, the pressure can cause sloughing of tissue flaps. Answer 1 is incorrect because the Hemovac exerts low, even pressure. Answer 2 is incorrect because the Hemovac is also lightweight (which is an advantage in postoperative ambulation), but this is not its primary advantage. Answer 4 is incorrect because the removal of excess sera reduces the likelihood of postoperative infection but is a secondary advantage. With more than one plausible choice, think of the purpose of the device. The nurse would expect to find drug abuse least prevalent in: An upper socioeconomic family. An elderly individual. A lower socioeconomic family. An adolescent. Although drug abuse may be found at every age level, the elderly seem least likely to abuse substances. This is probably due to generational differences in cultural norms and morals. (It was thought that one was "weak" or "sick" to rely on drugs to escape problems.) However, many times the elderly use alcohol as an escape mechanism. Answers 1 and 3 are incorrect because drug abuse is found among all socioeconomic classes. Answer 4 is incorrect because many adolescents use drugs to escape reality, cope with stress, identify with their peers, etc. The reasons for abuse vary from individual to individual, depending on their particular needs. Note key phrase: "least prevalent." A toddler has been in the hospital 1 week and refuses to talk with anyone, including the family. The toddler sits in the corner of the crib crying and rocking back and forth. The most important nursing intervention at this time should be to: Establish a one-to-one relationship with the toddler to develop trust. Assign different staff to work with the toddler each day to promote socialization. Ignore the behavior because it probably indicates normal regression. Refer the toddler to the pediatric clinical nurse specialist for further evaluation. The toddler is probably experiencing severe separation anxiety and is exhibiting symptoms of despair. A consistent one-to-one relationship will develop trust in the nurse; in addition, rooming-in by the mother should be encouraged. Answer 2 is incorrect because assigning different staff would increase anxiety stemming from feelings of uncertainty and lack of trust. Answer 3 is incorrect because ignoring the behavior may worsen the age-related separation anxiety. Answer 4 is incorrect: referral to the pediatric clinical nurse specialist may not be necessary at this time, as long as appropriate interventions are implemented. Choose one (consistent) staff nurse over different staff. Among the elderly, what is the most common postoperative complication following amputation? Hemorrhage and shock. Pulmonary embolus. Disseminated intravascular clotting. Thrombophlebitis. The most common complication occurring in the post operative period is pulmonary embolus. This is a particularly significant problem in elderly patients with a history of vascular insufficiency. Therefore, an antiembolism stocking is applied to the unaffected limb, and early physiotherapy and ambulation with a walker are encouraged. Answer 1 is incorrect because hemorrhage and shock are always potential problems after any surgery. To assess for this problem in this case, any bright-red drainage on the stump dressing should be outlined so that the rate of bleeding can be determined. Answer 3 is incorrect because disseminated intravascular clotting is a problem associated with prolonged shock. Answer 4 is incorrect because thrombophlebitis tends to occur with long bed rest and can be prevented. Think timing (postoperative) and age-specific problems.