Nclex 3500 424e2g

If rescue breathing is unsuccessful in a child under age 1, the nurse should deliver four back blows, followed by four chest thrusts, to try to expel the object from the obstructed airway. The nurse shouldn't perform chest compressions because the infant has a pulse and because chest compressions are ineffective without a patent airway for ventilation. The nurse shouldn't use abdominal thrusts for a child under age 1 because they can injure the abdominal organs. Self-acceptance is a generally accepted criterion of mental health and serves as the basis for healthy relationships with others. Some degree of anxiety is necessary to stimulate growth and adaptation. Self-control and self-direction — not the ability to control others — indicate mental health. Happiness, though desirable, isn't an effective indicator of mental health because even mentally healthy people may be unhappy when faced with such events as illness, loss, and death. After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40 ml/hr, and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hr. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters does the nurse calculate as urine?

: During 8 hours, 1,600 ml of bladder irrigation has been infused (200 ml × 8 hr = 1,600 ml/8 hr). The nurse then subtracts this amount of infused bladder irrigation from the total volume in the drainage bag (2,780 ml − 1,600 ml = 1,180 ml) to determine urinary output. Behavioral manifestations of Dysfunctional grieving include changes in eating habits, sleep patterns, and activity levels. Diagnoses of Activity intolerance, Ineffective role performance, and Impaired physical mobility don't include these defining characteristics.

Graves' disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-age females. In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, there is a low (≤2%) radioactive iodine uptake, and multinodular goiter will show an uptake in the high-normal range (3% to 10%). The primary purpose of istering corticosteroids to a child with nephrotic syndrome is to decrease proteinuria. Corticosteroids have no effect on blood pressure. Although they help reduce inflammation, this isn't the reason for their use in clients with nephrotic syndrome. Corticosteroids may predispose a client to infection. A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent. To detect skin cancer in its early stages, the nurse should emphasize the importance of monthly skin selfexaminations and yearly examinations by a physician. To reduce the risk of skin cancer, the nurse should teach clients to avoid the sun's ultraviolet rays between 10 a.m. and 3 p.m. Repeated exposure to artificial sources of ultraviolet radiation, such as tanning booths, increases the risk of skin cancer. While protective clothing offers some protection, some of the sun's harmful rays can penetrate clothing. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an

ectopic pregnancy. The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse should check any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) after notifying the physician because they may help explain the change in the

client's condition. The nurse should sign the preoperative checklist after notifying the physician of the client's condition and learning the physician's decision on whether to proceed with surgery. The physician prescribes heparin 25,000 U in 250 ml of normal saline solution to infuse at 600 U/hour for a client who suffered an acute myocardial infarction. After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The physician orders an increase in the infusion to 800 U/hour. The nurse should set the infusion pump to deliver how many milliliters per hour? 8 To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating with the blood, body fluid, mucous membranes, or nonintact skin of any client (such as when istering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause with blood or body fluids. The nurse should document the rate, rhythm, and amplitude of a client's pulse. Pitch, timing, and intensity aren't associated with pulse assessment. When providing care to a client, the nurse should consider family to be all the people whom the client views as family. Family may also include those people who provide for the physical and emotional needs of the client. The traditional definition of a family has changed and may include people not related by blood or marriage, those of a different racial background, and those who may not live in the same house as the client. Family are defined by the client, not by the nurse. Unusual occurrences and deviations from care are documented on incident reports. Incident reports are internal to the facility and are used to evaluate care, determine potential risks, or discover system problems that could have attributed to the error. This type of error won't result in a report to the state board of nursing or in suspension of the nurse. Some facilities do track the number of errors by a nurse or on particular units; the purpose of tracking errors is to provide appropriate education and to improve the nursing process. Activated charcoal binds to the ingested drug and is eliminated in the stool. Therefore, the client should have audible bowel sounds before the drug is given. Being able to follow commands isn't required; in some instances, the client may not be fully responsive. Ideally, an NG tube should be in place; however, an NG tube isn't necessary because the client can drink the activated charcoal. Advance directives aren't required for treatment. Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information. After assessing the client's chief complaint, the nurse should review the client's pertinent medical history; allergies, including a description of any reactions; any illness requiring treatment; major surgeries performed, including why and when; and current medications (both prescription and over-the-counter) and their purposes. This information allows the nurse to establish a baseline and determine the cause and urgency of the client's problem. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and

thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease. Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and with the client wearing similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable because they usually are subtle during early stages of fluid retention. Although

crackles indicate fluid accumulation in the lungs, weight gain is an earlier sign than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

If using I.V. bolus, ister by slow (50 mg/minute) I.V. push; too rapid of an injection may cause hypotension and circulatory collapse. Continuous monitoring of ECG, blood pressure, and respiratory status is essential when istering phenytoin I.V. Early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and slurred speech. Later, hypotension, arrhythmias, respiratory depression, and coma may occur. Death is caused by respiratory and circulatory depression. Phenytoin shouldn't be istered by I.V. push in veins on the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. Mix I.V. doses in normal saline solution and use within 30 minutes; mixtures with dextrose 5% in water will precipitate. Use of an inline filter is recommended. The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail. Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's abnormally rapid respirations.

respirations are rapid, deep breaths without pauses. Tachypnea is

To test for the Romberg's sign, which assesses balance, the nurse instructs the client to stand with feet together and arms at the sides while observing the client's ability to maintain balance — first with eyes open and then with eyes closed. Option 2 describes heel and toe walking, another test that evaluates balance. Option 3 describes a test used to evaluate motor function and range of motion. Option 4 describes a test used to assess coordination. : When maintaining a central venous catheter, the dressing should be changed every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should clean around the site using sterile technique, according to facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. The nurse should draw a circle around the moist spot and note the date and time if drainage is noted on a wound dressing. The physician should be notified if there are any complications observed related to the catheter. Only nurses with the appropriate qualifications can remove a central venous catheter, and a moist or loose dressing wouldn't be an indication for its removal. To perform light palpation, the nurse indents the client's skin ½" to ¾", using the tips and pads of the fingers. The nurse indents the skin approximately 1½" (3.8 cm) when performing deep palpation. The nurse indents the skin 1" and then releases the pressure quickly when eliciting rebound tenderness. During gentamicin therapy, the nurse should monitor a client's serum creatine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity. The drug isn't known to affect serum potassium or glucose levels or PTT. The nurse should always move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask isn't necessary. Using self-disclosure as a therapeutic communication technique encourages an open and authentic relationship between the nurse and her client. Self-disclosure involves the nurse revealing personal information. Clarification involves the nurse asking the client for more information. Reflection is reviewing the client's ideas. Restating is the nurse's repetition of the client's main message. Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. The other options — red or edematous surrounding tissue and serous drainage — are insufficient evidence that the wound is healing.

To reduce gastric reflux, the nurse should instruct the client to sleep with his upper body elevated; lose weight, if obese; avoid constrictive clothing, caffeine, and spicy foods; remain upright for 2 hours after eating; and eat small, frequent meals. A frontal or coronal plane runs longitudinally at a right angle to a sagittal plane, dividing the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions. Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. Creatine kinase-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. Blood urea nitrogen and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. A complete blood count won't give the nurse information on the effectiveness of therapy. With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended neck veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic

hypotension may occur.

When caring for a client with a cardiac disorder, the nurse should avoid using the rectal

route to take temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder. An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. In the apothecary system, the minim is the smallest liquid unit of measurement and the grain is the smallest solid unit of measurement. In the avoirdupois system, solids include the ounce and pound. In the metric system, the liter is used for liquids, the gram for solids. Tumors of the pituitary gland can lead to diabetes insipidus due to deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, weigh the client daily, measure urine specific gravity, and monitor intake and output. Encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect should be avoided.

Body surface area in relation to weight is the most reliable method for estimating proper medication dosage for a child. Body surface area is more accurate for dosage calculation than height or weight alone because height and weight vary widely. Developmental stage doesn't enter into dosage calculation. The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization. The dorsal cavity is divided into the cranial (skull) and vertebral canal (spinal cavity). The mediastinum and reproductive organs are located in the ventral cavity. The mouth is located in the oral cavity. Delegation of a process that will affect all aspects of a nursing area shows a lack of ability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff for their opinions of the solutions is characteristic of a participative manager.