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NURSING 2201 Med surge Evolve 100% Correct Answers with Rationales | Guaranteed Pass

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Med surge Evolve Answers with Rationales. Question: The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select... all that apply. Answer: "I have to avoid excessive exposure to sunlight." "I am at higher risk for skin cancer because my mother had one." Rationale: Options 1 and 3 describe risk factors for skin cancer. Additional risk factors for skin cancer include age greater than 60 years, light-colored skin, and occupation exposure to arsenic, which is commonly used in pest control. Question: The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? Answer: "Pain is due to stimulation of the affected nerve by pressure and temperature." Rationale: The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air. The remaining options are incorrect. Question: The nursing student is describing the differences between specific and nonspecific immunity to a group of classmates. Which statement made by the student to the classmates indicates accurate knowledge of specific immunity? Answer: "It is the second line of defense against infection." Rationale: Specific immunity is the second line of defense against infection. The body uses this process to identify specific antigens. With this type of immunity, different reactions occur in response to different antigens, and the response must be learned and developed. The remaining options identify nonspecific immunity. Which are possible causes of upper airway obstruction? Select all that apply. Laryngeal edema 3. Head and neck cancer 4. Foreign body aspiration 5. Lymph node enlargement Rationale: Obstruction of the upper airway can be due to obstruction by edema, a tumor, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway. A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? Rationale: The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect. A client arrives at the emergency department stating that a mosquito flew into his ear and that he is hearing a constant buzzing noise. Which intervention should the nurse take first? Look into the ear canal using a flashlight. Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Therefore, the first action would be to look into the ear canal using a flashlight. Substances such as viscous lidocaine may be prescribed to be instilled into the ear to suffocate the insect, which then is removed with the use of ear forceps. Irrigation may be necessary to flush the ear canal once the mosquito is killed, but this would not be the first action. A client is at risk for vasovagal attacks that cause bradydysrhythmias. The nurse would tell the client to avoid which actions to prevent this occurrence? Select all that apply. Applying pressure on the eyes . Raising the arms above the head. Bearing down during a bowel movement. Simulating a gag reflex when brushing the teeth. Rationale: Vasovagal attacks or syncope occurs when the client faints because the body overreacts to certain triggers. The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to the brain, causing the client to briefly lose consciousness. The client at risk should be taught to avoid actions that stimulate the vagus nerve. Actions to avoid include raising the arms above the head, applying pressure over the carotid artery, applying pressure over the eyes, stimulating a gag reflex when brushing the teeth or putting objects into the mouth, and bearing down or straining during a bowel movement. Taking stool softeners is an important measure to prevent the bearing down and straining during a bowel movement. The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. Spontaneous breathing. Oxygen saturation of 98%. Normal arterial blood gas levels. Vital capacity within normal range. Rationale: Satisfactory respiratory outcomes for a client with Guillain-Barré syndrome include clear breath sounds on auscultation, spontaneous breathing, normal vital capacity, normal arterial blood gas levels, and normal pulse oximetry. Adventitious breath sounds are an abnormal finding. A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? "I will take acetaminophen if I get a headache." Rationale: Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000. The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. Anterior cerebral artery. Internal carotid arteries. Posterior cerebral artery. Rationale: The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries. A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. Orthopnea and dyspnea. Petechiae and ecchymosis. Inguinal or umbilical hernia. Abdominal distention and tenderness. The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an altered immune system and the role of interferons is discussed. Which statement by the nursing student indicates a need for further teaching? "They are effective against a wide variety of bacteria." Rationale: Interferon is produced by several types of cells and is effective against a wide variety of viruses (not bacteria). It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. Interferons have been effective to some degree in the treatment of melanoma, hairy cell leukemia, renal cell carcinoma, ovarian cancer, and cutaneous T-cell lymphoma. The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? Tells the client that the procedure is painless and takes 30 to 60 minutes Rationale: Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client. The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. The T-piece is connected to the client's artificial airway. The client is removed from the mechanical ventilator for a short period of time. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting. A client who is receiving lithium carbonate has a serum level of 1.8 mEq/L. Which intervention will the nurse implement in response to this diagnostic result? Monitor the client for behaviors that suggests ataxia. Rationale: A serum lithium level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentrations of 1.5 to 2.5 mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching, and slurred speech. The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A level below that indicates a need for an increase in dosage. Fatigue is a common side effect of this medication. A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. Giving tepid sponge baths. Applying a hypothermia blanket. Administering acetaminophen per protocol Rationale: Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure. The mother of a 3-year-old boy calls the emergency department and states that she found an empty bottle of acetaminophen on the floor. She states that she thinks her child ingested all of the medication. What is the priority question for the nurse to ask the mother? "Is your child breathing okay?" Rationale: Airway is always the highest assessment data to obtain during a poison control call. Once this information is obtained, the child's neurological status can be determined in terms of his orientation and other information, such as that referred to in the remaining options. When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? Select all that apply. Admitting the client to a room near the nurses' station. Arranging for a security officer to be nearby and available but out of the client's sight. Rationale: The nurse should not isolate herself or himself with a potentially violent client. The client should be placed in a room near the nurses' station and not at the distant end of a corridor. The nurse should strive to maintain eye contract with the client as a means of therapeutic communication. A security officer should be readily available and visible to the client if there is a possibility of imminent violence. The door to the client's room should remain open when giving care. The nurse is reviewing medical record notes of a client with bladder cancer who is prescribed concentrations of methotrexate followed by leucovorin (citrovorum factor, folic acid). The nurse should include in the client's education which information about the anticipated therapeutic effect of leucovorin? "It will help to preserve normal cells." Rationale: The administration of leucovorin with methotrexate is known as leucovorin rescue. High concentrations of methotrexate cause harm and damage to normal cells. Leucovorin bypasses the metabolic block caused by methotrexate, thereby permitting normal cells to synthesize. Leucovorin rescue is potentially hazardous because failure to administer leucovorin in the right dose at the right time can be fatal. Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. 25drops/min Rationale: Use the intravenous (IV) flow rate formula. Formula: Total volume × Drop factor –––––––––––––––––––––––––– = gtt/min Time in minutes 50 mL × 15 gtt 750 –––––––––––––– = ––– = 25 gtt/min 30 minutes 30 The nurse is caring for a client who is dying. The nurse recognizes that which intervention is likely to facilitate therapeutic communication between the dying client and his or her family? Select all that apply. The nurse encourages the client and family to identify and discuss feelings openly. The nurse assists the client and family in carrying out spiritually meaningful practices. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. The nurse is supportive and nonjudgmental of the client's or family's verbalized concerns and feelings. Rationale: The incorrect option describes an intervention in which the nurse removes autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention and could further impair communication. Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Encouraging discussion of feelings is likely to enhance communications. Spiritual practices give meaning to life and have an impact on how people react to crisis, so it is also an effective intervention. The client and family need to know that someone will be there who is supportive and nonjudgmental. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. Draw 1 line through the error, initialing and dating it. Document the correct information and end with the nurse's signature and title. Which assessment finding would be a manifestation associated with dementia? Confabulation Rationale: The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or fabrication of events or experiences to fill in memory gaps is common. Ritualistic behaviors are associated with obsessive-compulsive disorder, while catatonia is a psychotic reaction. Often, lack of inhibition on the part of the client constitutes the first indication to the client's significant others that something is "wrong." 100 questions. The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse would monitor the child specifically for central nervous system involvement by checking which item? Level of consciousness. Rationale: The central nervous system (CNS) status is monitored in the child with leukemia because of the risk of infiltration of blast cells into the CNS. The nurse should check the child's level of consciousness (LOC) and should also monitor for signs of irritability, vomiting, and lethargy. Changes in pupillary reaction are specific to conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign that may be noted in leukemia but is not specifically related to the CNS. Color, motion, and sensation of the extremities relate to a neurovascular assessment and are not specifically related to CNS status. The nurse is caring for a child following a tonsillectomy. The nurse should reposition the child on return from the operating room if the child is in which position? Supine Rationale: Supine position should be avoided because it does not facilitate drainage from the oral cavity after tonsillectomy. The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage. The nurse is reviewing the record of a client who was admitted to the hospital with a diagnosis of ovarian cancer. A client has received an unsealed radioactive isotope for treatment of thyroid cancer. Which instruction is essential for the nurse to provide the client? "Flush the toilet at least 3 times after use." Rationale: Bodily fluids contain the radioactive material, so others should be shielded from possible exposure. Clients should at best have a dedicated toilet for use during the first 2 weeks and should also flush 3 times after use. Some radioactivity will be in the saliva for about the first week, so during this time fruits with cores that will become contaminated should be avoided. Disposable eating utensils should also be used during this period of time. Contact with pregnant women, infants, and children is avoided for the first week and then a distance of 3 feet (1 meter) or more should be maintained and exposure should be limited to 1 hour per day. The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is neededif the mother states that she will include which food item in the child's nutritional plan? Oatmeal Rationale: Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse reviews the health care provider's (HCP's) prescriptions, expecting to note a prescription for which laboratory test while this client is taking the medication? Serum creatinine level Rationale: Foscarnet is an antiviral medication that is very toxic to the kidneys. Serum creatinine is monitored before therapy, 2 to 3 times weekly during induction therapy, and at least once weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium in the bloodstream. Thus, these levels also are measured with the same frequency. The laboratory tests in the remaining options are not specific to this medication. The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum Rationale: Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations. A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. Dyspnea at rest Clubbed fingers Muscle retractions Prolonged expiratory breathing phase The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. History of headaches Previous back injury History of hypertension Rationale: Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem History of diabetes mellitus A client admitted to the hospital is taking capecitabine. The nurse should monitor the client for which symptom that is a side or adverse effect of the medication? Dyspnea Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. Headache, constipation, and dizziness are not adverse effects of this medication. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. Record site, date, and time of the test. Give the client a list of potential allergens if identified Cerebral palsy (CP) is suspected in a child and the parents ask the nurse about the potential warning signs of CP. The nurse should provide which information? Select all that apply. The infant's arms or legs are stiff or rigid. A high risk factor for CP is very low birth weight. The infant has feeding difficulties, such as poor sucking and swallowing. If the infant is able to crawl, only one side is used to propel himself or herself. The health care provider (HCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed? "It is an antibody found on the surface of the red blood cell." Rationale: The major blood types are A, B, AB, and O. The blood type indicates an antigen, not an antibody, found on the surface of the red blood cell. The other responses are accurate statements. The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply. Notify the health care provider (HCP). Prepare for endotracheal tube (ET) placement. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply Administer stool softeners as prescribed. Encourage a high-fiber diet to promote bowel movements without straining. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. The health care provider prescribes 1000 mL of 0.9% normal saline to run over 8 hours. The drop factor is 10 drops (gtt)/mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number. Rationale: The prescribed 1000 mL is to be infused over 8 hours. Follow the formula and multiply 1000 mL by 10 (drop factor). Then divide the result by 480 minutes (8 hours × 60 minutes/hour). The infusion is to run at 20.8, or 21, gtt/min. 21gtt/min Total volume × Drop factor –––––––––––––––––––––––––– = gtt/min Time in minutes 1000 mL × 10 gtt 10,000 –––––––––––––––– = –––––– = 20.83 gtt/min 480 minutes 480 = 21 gtt/min (rounded) The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching? "This test measures the levels of all of the medications that I take." Rationale: A creatinine clearance test does not measure levels of a client's medications but measures the glomerular filtration rate of the kidneys and how effectively the kidneys can eliminate substances. The other options are accurate statements. Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? The client is convinced that the curtains are actually ghosts. Rationale: A delusion is a personal belief that is the product of dysfunctional processing of information derived from external reality. This cognitive processing dysfunction is the basis of schizophrenia. Catatonia is a stuporous state that renders the client incapable of physical movement. Magical thinking is a result of concrete thinking that causes the client to interpret a statement literally. Hallucinations are the result of distortions in perceptions of the senses, but they are not reliant on internal or external stimuli. 100 questions The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? "I need to perform good oral hygiene, including flossing and brushing my teeth." Rationale: Phenytoin is an anticonvulsant used to treat seizure disorders. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should perform good oral hygiene, including flossing and brushing the teeth. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages. A child admitted to the hospital with a diagnosis of gastroenteritis and dehydration weighs 17 pounds 2 ounces (7.8 kg). The parents state that his preadmission weight was 18 pounds 4 ounces (8.3 kg). Based on weight alone, what type of dehydration does the nurse expect? Moderate dehydration Rationale: Mild dehydration is a weight loss less than 5%; moderate dehydration is 5% to 10%; severe dehydration is greater than 10% weight loss. All types of dehydration are acute situations. The answer can be determined by calculating the percent of weight loss in dehydration. Because the math calculation determines more than a 5% weight loss but less than 10% weight loss, the correct answer is moderate dehydration. By calculating the percent of weight loss, the correct answer can be determined. The nurse is monitoring a stress management therapy group that is in the forming stage. Which activity is characteristic of this stage of group development? Rationale: Setting the rules of conduct for members of the stress management group In the forming or initial stage, the members are identifying tasks and boundaries (setting rules). Storming involves responding emotionally to tasks. In the norming stage, members express intimate personal opinions and feelings concerning personal tasks (options 1 and 2). In the performing stage, members direct group energy toward the completion of tasks (option 4). The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. Providing sensory cues Giving simple, clear directions Providing a stable environment Keeping family pictures at the bedside Rationale: Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside. The nurse is monitoring a client who is receiving intravenous (IV) acyclovir. The nurse would monitor the client closely for which primary toxic effect of the medication? Nephrotoxicity Rationale: Acyclovir is an antiviral medication. Although the most common side and adverse reactions with this medication are phlebitis and inflammation at the IV site, reversible nephrotoxicity, evidenced by elevated serum creatinine and BUN levels, can occur in some clients. The cause of nephrotoxicity is deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and the use of other nephrotoxic medications. Ototoxicity, neurotoxicity, and cardiotoxicity are not specific to this medication. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? Slow the IV infusion. Rationale: The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication. The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism? An elevated TSH level Rationale: Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition. The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. Risk for unsafe conditions because of homelessness Anxiety when consciousness is regained because of the unfamiliar surroundings Risk for infection because of his unkempt condition, various scratches, and homelessness Rationale: Infection is a priority because of the client's poor hygiene, altered skin integrity, and homelessness. Injury is also a concern because of the client's situation (homelessness). Waking up in an unfamiliar place can lead to anxiety. No data in the question indicate that the client has confusion or lacks knowledge. Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. Reduce exposure to environmental organisms. Use strict aseptic technique for all procedures. Ensure that anyone entering the child's room wears a mask. Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the child's room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not leaving standing water in the child's room. Applying firm pressure to a needle-stick area for at least 10 minutes is a measure to prevent bleeding. The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. Pulsus paradoxus Distant heart sounds Falling blood pressure (BP] Distended jugular veins Rationale: Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling BP, accompanied by pulsus paradoxus (a drop in inspiratory BP by more than 10 mm Hg). A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. Comatose state Deep, rapid breathing Elevated blood glucose level Rationale: Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria Which is considered a normal finding in a newborn less than 12 hours old? Has not passed meconium yet Rationale: Meconium is the name for the first greenish black, tarry stools that the newborn will pass. It is possible that meconium may not be passed for as long as 24 to 48 hours. The WBC count is excessive for a newborn.The total serum bilirubin level is also excessive in the first 24 hours of life. Seesaw respirations indicate a respiratory problem. The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse should instruct the client that which is the first step in this procedure? Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. Rationale: The initial step in preparing an injection of insulin that is a mixture of NPH and regular insulin is to inject air into the NPH insulin bottle equal to the amount of insulin prescribed. The client would then be instructed to inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin would then be withdrawn, followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer acting form. The nurse is teaching a group of adults about the warning signs of cancer. Which signs and symptoms should the nurse mention to the group? Select all that apply. Sores that do not heal Nagging cough or hoarseness Indigestion or difficulty swallowing Change in bowel or bladder habits Rationale: Foods and fluids that acidify, not alkalinize, the urine should be encouraged. The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder. the nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign? Bluish discoloration of cervix and vagina Rationale: The cervix undergoes significant changes after conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Darkening of the areola occurs during pregnancy but is not related to Chadwick's sign. Softening of the uterine isthmus is known as Hegar's sign. The presence of the uterus (fundal height) just above the symphysis pubis dates the pregnancy to be about 13 weeks' gestation. [Show More]

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