1.

Normal plasma osmolality: 275-295 "The surgery will relieve the symptoms but will not side effects, other types of treatments available,
2. Most common type of dehydration: Isotonic cure your father." and the effects without the procedure.
3. Isotonic dehydration results in DECREASED
circulating blood volume and INADEQUATE Twenty minutes after a client has received a A nurse caring for a patient with a pulmonary
tissue perfusion preoperative injection of atropine and midazolam embolism understands that a high ventilation-
4. Causes of Isotonic Dehydration: inadequate (Versed), the client tells the nurse that he must be perfusion ratio may exist. This means that:
intake of F/E; fluid shifts between compartments; allergic to the medication because his mouth is Ventilation exceeds perfusion
excessive losses of isotonic body fluids dry and his heart seems to be beating faster than
5. Causes of Hypertonic Dehydration: excessive normal. What is the nurse's priority action? A nurse understands that a safe but low level of
perspiration; hyperventilation; ketoacidosis; Assess the client's pulse and blood pressure. oxygen saturation provides for adequate tissue
prolonged fever; diarrhea; ERKD diabetes saturation but allows no reserve for situations that
insipidus A client undergoing preoperative assessment threaten ventilation. A safe but low oxygen
6. Causes of Hypotonic Dehydration: chronic informs the nurse that he takes medication for saturation level is: 40 mm Hg
illness; excessive fluid replacement; kidney high blood pressure and for asthma. What is the
disease; chronic malnutrition nurse's best action? Notify the surgeon and the When taking a respiratory history, the nurse
7. Incentive spirometer: helps with lung anesthesiologist. should assess:
expansion, prevents atelectasis The previous history of lung disease in the patient
8. Coughing: mobilize secretions, reduces Which action is most appropriate during a or family, occupational and environmental
complications for atelectasis and pneumonia preoperative chart review? influences, smoking and exposure to allergies
9. Ambulation: Improve circulation, prevent Ensure that the consent form is signed, dated,
venous stasis; promote respiratory function and witnessed. Bacterial pneumonia can be indicated by the
10. Priority of preoperative assessment: Patient presence of all of the following EXCEPT: thin,
Safety Four clients are scheduled for surgery. Which mucoid sputum
11. Preop Meds include: Sedatives, Anti-anxiety, client does the nurse determine is at highest risk *Can be indicated by green, purulent sputum;
Muscle Relaxants, Anticholinergics, GI for postsurgical complications? thick, yellow sputum; rusty, sputum
Medications 89-year-old scheduled for a knee replacement
12. The primary goal in withholding food before Nursing assessment for a patient with chest pain
surgery is to prevent aspiration. The nurse is conducting preoperative includes:
13. Primary objective during immediate assessments. Which client does the nurse teach Determining whether there is a relationship
postoperative assessment is to maintain about the possibility of developing a venous between the pain and the patient's posture,
respiratory function (ventilation) and hypovolemia thromboembolism (VTE)? Client undergoing hip evaluating the effect of the phases of respiration
and hypercapnia. replacement surgery on the pain, looking for factors that precipitate the
14. A client voluntarily signed the operative pain
consent form. What is the nurse's next action? The nurse applies antiembolism stockings to a
Sign under the client's name as a witness. client preoperatively. When the client says that Chest pain described as knifelike on inspiration
15. The nurse is caring for an older adult client they are uncomfortably tight, what is the nurse's would most likely be diagnostic of: Pleurisy
with a history of chronic lung disease who will be best action? Teach the client the purpose of
undergoing surgery the following day. When wearing the stockings. Hemoptysis, a symptom of cardiopulmonary
postoperative care is planned, which potential disorders, is characterized by all of the following
problem is the highest priority for this client? The nurse is assessing a client before surgery. EXCEPT: a coffee ground appearance
Maintaining oxygenation Which assessments contraindicate the client *IS characterized by an alkaline pH, sudden
having surgery as scheduled? onset, bright red bleeding mixed with sputum
The nurse reviews a client's laboratory results Potassium level of 2.8 mEq/L, International
before surgery and notes a fasting blood glucose normalized ratio (INR) of 4, Positive pregnancy A patient exhibits cyanosis when how much
of 120 mg/dL, a prothrombin time (PT) of 25 test hemoglobin is unoxygenated? 5.0 g/dL
seconds, and potassium (K+) of 3.8 mEq/L.
Which action by the nurse is best? Which medications does the nurse correctly The nurse inspects the thorax of a patient with
Ask the surgeon for additional laboratory studies. administer preoperatively? advanced emphysema. The nurse expects chest
Hydroxyzine (Atarax, Vistaril) for sedation, configuration change consistent with a deformity
A client is brought to the emergency department Lorazepam (Ativan) for anxiety, Metoclopramide known as: barrel chest
(ED) after a motorcycle accident. The client has (Reglan) to increase stomach emptying
suffered a ruptured spleen. What is the immediate Breath sounds that originate in the smaller
priority? Emergent surgery to control bleeding The nurse is conducting preoperative teaching bronchi and bronchioles and are high-pitched,
with a client who will be undergoing pelvic sibilant, and musical are called: wheezes
The nurse has just completed preoperative surgery. What teaching is essential for this client?
teaching with a client who will be having surgery "Wearing elastic stockings and using pneumatic Crackles, noncontiguous breath sounds, would be
the following day. Which statement by the client compression devices are essential after surgery.", assessed for a patient with: collapsed alveoli
indicates that additional teaching is needed? "Coughing and deep breathing will help to
"I will go to the bathroom as soon as I receive all decrease postoperative complications.", "Turning During a preadmission assessment, the nurse
my preoperative medications." and moving your legs after surgery will help would expect to find decreased tactile fremitus
prevent clots from forming." and hyperresonant percussion sounds with a
The nurse is performing preoperative teaching diagnosis of: emphysema
with an older adult client who will be having colon What data are essential for the nurse to assess
resection surgery the following day. The surgeon on a client who is scheduled for surgery? Use of The arterial blood gas measurement that best
has ordered bowel preparation the night before. tobacco, Current medications, Use of herbal or reflects the adequacy of alveolar ventilation is the:
Which action is a priority? over-the-counter therapy, mental status PaCO2
Tell the client not to get up and go to the examination, Allergies
bathroom alone. Nursing directions to a patient from whom a
The nurse is preparing to transfer a client to the sputum specimen is to be obtained should include
When examining an adult client's preoperative operating room for surgery. Put the interventions all of the following EXCEPT directing the patient
laboratory results, the nurse notes that the in order for the nurse to perform. to: spit surface mucus and saliva into a sterile
potassium level is 2.9 mEq/mL. What is the Ask the client to state his or her name and check specimen container
nurse's priority action? Notify the surgeon the ID band, Have the client go to the bathroom to *directions include initially clear his or her nose
void, Take a full set of vital signs, Administer and throat, take a few deep breaths before
What recently learned information about a client ordered preoperative sedation coughing, use diaphragmatic contractions to aid
who is scheduled to have surgery within the next A client is having elective surgery under general in the expulsion of sputum
2 hours is the nurse certain to communicate to the anesthesia. Who is responsible for obtaining the
surgical team? Hearing problem informed consent? A physician wants a study of diaphragmatic
It is the role of the surgeon or the person motion because of suspected pathology. The
A client will be undergoing palliative surgery. The performing the procedure to obtain the informed physician would most likely order a:
client's daughter asks what this means. What is consent. This consists of informing the client Fluoroscopy
the nurse's best response? about the procedure, the risks of treatment, the
Distinguish between the terms ventilation and 429. A child with laryngotracheobronchitis (croup) A patient was admitted after a motor vehicle
respiration. is placed in a cool mist tent. The mother becomes accident with multiple fractured ribs. Respiratory
Ventilation refers to the movement of air in and concerned because the child is frightened, assessment includes signs/symptoms of
out of the airways, whereas respiration refers to consistently crying and trying to climb out of the secondary pneumothorax, which includes which
gas exchange between atmospheric air and blood tent. Which is the MOST APPROPRIATE nursing of the following?
and between the blood and the cells of the body. action? Let the mother hold the child and direct A: Sharp pleuritic pain that worsens on inspiration
the cool mist over the child's face.
Describe the function of the epiglottis. A patient has been newly diagnosed with
The epiglottis is a flap of cartilage that covers the 431. The mother of a hospitalized 2 year old child emphysema. In discussing his condition with the
opening of the larynx during swallowing. with viral laryngotracheobronchitis (croup) asks nurse, which of his statements would indicate a
the nurse why the health care provider did not need for further education?
List four conditions that cause low compliance or prescribe antibiotics. Which response should the D: "If I get short of breath, I'll turn up my oxygen
distensibility of the lungs: morbid obesity, nurse make? "Antibiotics are not indicated unless level to 6 L/min."
atelectasis, pneumothorax, hemothorax, a bacterial infection is present."
pulmonary fibrosis or edema, pleural effusion, and The nurse goes to assess a new patient and finds
ARDS 432. The nurse is caring for an infant with him lying supine in bed. The patient tells the
bronchiolitis, and diagnostic tests have confirmed nurse that he feels short of breath. Which nursing
The alveoli begin to lose elasticity at about respiratory syncytial virus (RSV). On the basis of action should the nurse perform first?
age____ years, resulting in decreased gas this finding, which is the MOST APPROPRIATE A: Raise the head of the bed to 45 degrees.
diffusion: 50 nursing action? The nurse is caring for a patient who exhibits
2. Move the infant to a room with another child labored breathing and uses accessory muscles.
List six major signs and symptoms of respiratory with RSV. The patient has crackles in both lung bases and
disease. diminished breath sounds. Which would be
dyspnea, cough, sputum production, chest pain, 433. The nurse is preparing for the admission of priority assessments for the nurse to perform?
wheezing and hemoptysis an infant with a diagnosis of bronchiolitis caused A: SpO2 levels
by respiratory syncytial virus (RSV). Which B: Amount of sputum production
List for conditions that are influenced by genetic interventions should the nurse include in the plan C: Change in respiratory rate and pattern
factors that affect respiratory function: of care? SELECT ALL THAT APPLY.
asthma, COPD, cystic fibrosis, and alpha-1 1. Place the infant in a private room. Which of the following statements made by a
antitrypsin deficiency 6. Ensure that nurses caring for the infant with student nurse indicates the need for further
RSV do not care for other high-risk children. teaching about suctioning a patient with an
Explain the breathing pattern characterized as endotracheal tube?
Cheyne-Stokes respirations. A patient who started smoking in adolescence D: "I'll instill 5 mL of normal saline into the tube
Cheyne-Stokes respirations are characterized by and continues to smoke 40 years later comes to before hyperoxygenating the patient."
alternating episodes of apnea (cessation of the clinic. The nurse understands that this patient
breathing) and periods of deep breathing. It is has an increased risk for being diagnosed with Two hours after surgery the nurse assesses a
usually associated with heart failure and damage which disorder: D: Cardiopulmonary disease and patient who had a chest tube inserted during
to the respiratory center. lung cancer surgery. There is 200 mL of dark-red drainage in
the chest tube at this time. What is the
Which diagnostic is the most accurate in A patient has been diagnosed with severe iron appropriate action for the nurse to perform?
assessing acute airway obstruction? Pulmonary deficiency anemia. During physical assessment A: Record the amount and continue to monitor
function studies for which of the following symptoms would the drainage
Explanation: nurse assess to determine the patient's oxygen
Pulmonary function studies are the most accurate status? Which nursing intervention is appropriate for
means of assessing acute airway obstruction. D: Decreased activity tolerance and increased preventing atelectasis in the postoperative
ABGs, pulse oximetry, and chest x-ray are not the breathlessness patient? C: Incentive spirometer
most accurate diagnostics for an airway
obstruction A patient is admitted to the emergency The nurse needs to apply oxygen to a patient who
department with suspected carbon monoxide has a precise oxygen level prescribed. Which of
A 10 year old child with asthma is treated for poisoning. Even though the patient's color is the following oxygen-delivery systems should the
acute exacerbation in the emergency department. ruddy, not cyanotic, the nurse understands that nurse select to administer the oxygen to the
The nurse caring for the child should monitor for the patient is at a risk for decreased oxygen- patient? A: Nasal cannula
which sign, knowing that it indicates a worsening carrying capacity of blood because carbon
of the condition? Decreased wheezing monoxide does which of the following: In neonatal resuscitation, which should be done
Forms a strong bond with hemoglobin, creating a first?
The mother of an 8 year old child being treated for functional anemia. d. Dry the infant and position the head.
right lower lobe pneumonia at home calls the
clinic nurse. The mother tells the nurse that the A 6-year-old boy is admitted to the pediatric unit Of all of the signs seen in infants with respiratory
child complains of discomfort on the right side and with chills and a fever of 104°F (40°C). What distress syndrome, which one is especially
that ibuprofen (Motrin IB) is not effective. Which physiological process explains why the child is at indicative of the syndrome?
instruction should the nurse provide to the risk for developing dyspnea? c. Grunting
mother? Encourage the child to lie on the right A: Fever increases metabolic demands, requiring
side. increased oxygen need. Which of the following should the nurse recognize
as a possible maternal-infant blood group
426. A new parent expresses concern to the A patient is admitted with the diagnosis of severe incompatibility?
nurse regarding sudden infant death syndrome left-sided heart failure. The nurse expects to a. The mother is O positive and the infant is O
(SIDS). She asks the nurse how to position her auscultate which adventitious lung sounds? D: negative.
new infant for sleep. In which position should the Inspiratory crackles in lung bases b. The mother is A positive and the infant is A
nurse tell the parent to place the infant? Back negative.
rather than on the stomach The nurse is caring for a patient who has c. The mother is O positive and the infant is B
decreased mobility. Which intervention is a simple negative.
427. The clinic nurse is providing instructions to a and cost-effective method for reducing the risks of d. The mother is B positive and the infant is O
parent of a child with cystic fibrosis regarding the stasis of pulmonary secretions and decreased negative.
immunization schedule for the child. Which chest wall expansion? B: Frequent change of ANS: C
statement should the nurse make to the parent? position
Which of the following might the nurse expect
428. The emergency department nurse is caring A patient is admitted with severe lobar when a cardiac defect causes mixing of arterial
for a child diagnosed with epiglottitis. In assessing pneumonia. Which of the following assessment and venous blood in the right side of the heart?
the child, the nurse should monitor for which findings would indicate that the patient needs a. Cyanosis
indication that the child may be experiencing airway suctioning? b. Signs of pulmonary congestion
airway obstruction? The child is leaning forward, C: Decreased independent ability to cough c. Increased oxygenation of the tissues
with the chin thrust out. d. Diuresis
ANS: B
 c. There was no meconium below the vocal cords --High frequency (Oscillator or Jet: 200-900
The infant of a diabetic mother is hypoglycemic. when they were visualized. breaths per minute to keep lungs expanding all
The type of feeding that should be instituted first d. The parents spent an hour bonding with the the time)
is: baby after birth.
a. Small amount of glucose water followed by ANS: C Respiratory Equipment Complications
formula or breast milk. Retinopathy of Prematurity (ROP):
b. D5W intravenously. What intervention would make phototherapy most
c. Formula via nasogastric tube. effective in reducing the indirect bilirubin in an Broncho-pulmonary Dysplasia (BPD)
d. Glucose water. affected newborn?
ANS: A a. Turn the infant every 2 hours. Retinopathy of Prematurity (ROP)
b. Increase oral intake of water between and Injury to the blood vessels in the eye bc they're
Which defect is present with tetralogy of Fallot? before feedings. not fully formed yet.
a. Coarctation of the aorta c. Place eye patches on the newborn.
b. Hypertrophy of the right ventricle d. Wrap the infant in triple blankets to prevent Can cause a leak, rupture, hemorrhage, scarring,
c. Transportation of the great arteries cold stress. and even detachment of the retina, causing visual
d. Patent ductus arteriosus ANS: A impairment or blindness.
ANS: B
Newborns whose mothers are substance abusers Can resolve on it's own most of the time.
The nurse is responsible for monitoring the frequently have which behaviors?
feedings of the infant with hyperbilirubinemia a. Circumoral cyanosis, hyperactive Babinski ROP Risk Factors
every 2 to 3 hours around the clock. The purpose reflex, and constipation High levels of oxygen
of these formula- or breast-feedings is to: b. Decreased amounts of sleep, hyperactive Moro Prolonged ventilation
a. Prevent hyperglycemia. reflex, and difficulty feeding Sepsis
b. Provide fluids and protein. c. Hypothermia, decreased muscle tone, and
c. Decrease gastrointestinal motility. weak sucking reflex (Exact cause is unknown)
d. Prevent rapid emptying of the bilirubin from the d. Excessive sleep, weak cry, and diminished
bowel. grasp reflex ROP Treatment/Prevention
ANS: B ANS: B Screenings to detect changes in the eye until
retina is mature (about a month or so)
Four hours after the delivery of a healthy neonate In an infant with cyanotic cardiac anomaly, the
of an insulin-dependent (type 1) diabetic mother, nurse would expect to see: Can do laser treatment to prevent retina damage.
the baby appears jittery, irritable, and has a high- a. Feedings taken eagerly.
pitched cry. Which nursing action has top priority? b. A decrease in the heart rate with activity. Bronchopulmonary Dysplasia (BPD)
a. Start an intravenous line with D5W. c. Little to no improvement in color with oxygen Injury to bronchial epithelium and interferes with
b. Notify the clinician stat. administration. alveolar development
c. Document the event in the nurses' notes. d. A consistent and rapid weight gain.
d. Test for blood glucose level. ANS: C BPD S/S
ANS: D Increased need for or an inability to be weaned
The difference between pathologic jaundice and from respiratory support and oxygen
Which newborn would the nurse recognize as physiologic jaundice is that pathologic jaundice: Tachycardia
being most at risk for developing respiratory a. Usually results in kernicterus. Respiratory acidosis
distress syndrome? b. Appears during the first 24 hours of life.
a. A 35-week-gestation female baby born c. Results from breakdown of excessive Will be in and out of hospital for the first 2 years of
vaginally 72 hours after the rupture of membranes erythrocytes not needed after birth. life with resp infections bc of the damage done.
b. A 36-week-gestation male baby born by d. Begins on the head and progresses down the
cesarean delivery to a mother with insulin- body. BPD Prevention/Treatment
dependent diabetes ANS: B Prevention
c. A 35-week-gestation male baby born vaginally -Maternal steroids (BETAMETHAZONE)
to a mother addicted to heroin While caring for a postterm infant, a nurse -Minimizing exposure to oxygen and pressure
d. A 35-week-gestation female baby born recognizes that the elevated hematocrit level with ventilation
vaginally to a mother who has pregnancy-induced most likely results from:
hypertension a. Hypoxia in utero. Treatment - supportive
ANS: B b. Underproduction of red blood cells. -Antibiotics and bronchodilators as necessary
c. Increased breakdown of red blood cells. -Gradual decreases in amount of oxygen
Transitory tachypnea of the newborn (TTN) is d. The normal expected shift from fetal
thought to occur as a result of: hemoglobin to normal hemoglobin. Periventricular-Intraventricular Hemorrhage
a. A lack of surfactant. ANS: A (PIVH)
b. Hypoinflation of the lungs. -Bleeding around and into the ventricles of the
c. Delayed absorption of fetal lung fluid. Why is maternal diabetes a risk factor for RDS? brain due to rupture of fragile blood vessels in the
d. A slow vaginal delivery associated with Because insulin blocks the effect of cortisol, which germinal matrix
meconium-stained fluid. is involved in surfactant production. So because
ANS: C of their increase in insulin, they have reduced -Occurs most commonly within first 72 hours of
surfactant. life
The nurse must continually assess the infant who
has meconium aspiration syndrome for the RDS Treatment/Prevention -Most often associated with hypoxic injury to the
complication of: Incidence and severity reduced by giving mother vessels, increased or decreased blood pressure,
a. Persistent pulmonary hypertension. corticosteroids (BETAMETHASONE) before birth and increased or fluctuating cerebral blood flow
b. Bronchopulmonary dysplasia.
c. Transitory tachypnea of the newborn. Artificial surfactant: intubate them and administer. PIVH S/S
d. Left-to-right shunting of blood through the This will increase the surfactant production and -Lethargy
foramen ovale. increase their survival rate -Poor muscle tone
ANS: A -Deterioration of respiratory status with cyanosis
Respiratory Equipment: Oxygen/ventilation or apnea
The nurse present at the delivery is reporting to support -Decreased reflexes
the nurse who will be caring for the neonate after Nasal cannula -Full or bulging fontanel
birth. What information might be included for an -Seizures (late sign)
infant who had thick meconium in the amniotic Oxyhood
fluid? PIVH Complications
a. The infant needed vigorous stimulation Continuous positive airway pressure (CPAP) -Hydrocephalus: Bleeding in brain causes blood
immediately after birth to initiate crying. clots in drainage areas for CSF, so the CSF starts
b. An IV was started immediately after birth to Ventilator (Intubation) to increase, causing hydrocephalus bc the blood
treat dehydration. --Conventional clots are blocking drainage. May need to get a
shunt.
 -Rapid respirations after birth followed by Limp
-Life-long neurological deficits, specifically cessation of respirations and rapid fall of HR Retractions
cerebral palsy -Gasping Nasal flaring
-Developmental delay -Loss of consciousness Grunting
-Seizures Barrel-shaped chest
Resuscitation may be required
PIVH Prevention/Treatment MAS Risk factors
Prevention: Betamethazone Asphyxia complications At Risk:
metabolic acidosis (with anaerobic metabolism- Postterm babies - Poop because they're stressed
Management producing lactic acid) bc of lack of oxygen (hypoxia or asphyxia) and
-Screening of at risk preemies (ultrasound of Hypoglycemia placenta isn't nourishing them anymore. Hypoxic
anterior fontanel) hypothermia event causes increased peristalsis and relaxes
-Supportive: maintain respiratory function hypotension the anal sphincter.
feeding problems
PIVH Nursing care seizures SGA
-Daily head circumference F/E imbalances
-Observe for changes in neurologic status MAS Therapeutic Management
-Elevate head 30° Asphyxia treatment/mngmnt Airway clearance: Tracheal suctioning
Close monitoring
Necrotizing Enterocolitis (NEC) Supportive care
Serious, acute inflammatory condition of intestinal Parental support -Oxygen/ventilation support
tract that may lead to cellular death of areas of -Extracorporeal membrane oxygenation (ECMO)
intestinal mucosa Brain/Body cooling: cold mattress with cold cap -Nitric oxide gas to dilate pulmonary vessels
over head to decrease temperature & metabolic -Monitor for infection: damaged lungs are good
Can be due to: hypoxia and the bacteria that has rate to save whatever brain is left. Can't take reservoir for bacteria
been growing inside the intestine from the away injury, but trying to prevent further damage.
damage. Area is dead now and aren't able to eat. Hyperbilirubinemia
Belly blows up, becomes tender, and may require Transient tachypnea of the newborn (TTN) (Pathologic jaundice)
immediate surgery bc it can rupture/perforate, "Wet lung" Excessive amount of bilirubin (byproduct of
which would be deadly. Baby develops rapid respirations soon after birth. breakdown of RBC) in blood
Delayed absorption of fetal lung fluid by
Occurs in 1%-5% of infants admitted to NICUs pulmonary capillaries and lymph vessels. Can't Hyperbilirubinemia Risk Factors
Often fatal (25%-35%) get air out of lungs because of the fluid in the -Hemolytic disorders are #1 cause (Rh
Exact cause unknown lungs. incompatibility)
-Infection
NEC s/s TTN Risk Factors -Hypoxia
-Increased abdominal girth Male gender -Infant of diabetic mothers: Polycythemia bc they
-Increased gastric residuals Cesarean birth without labor; prolonged or need more oxygen. They have so many fetal RBC
-Decreased or absent bowel sounds precipitous labor that have to die off.
-Visual bowel loops (bc food and air is trapped in Asphyxia
the bowel. Can see on X-Ray) Macrosomia Coombs Test
-Bilious vomiting Maternal diabetes or asthma Rh compatibility.
-Occult blood in stools Multiple gestation Positive: Maternal antibodies are attacking the
-Signs of infection Excessive maternal sedation baby's fetal hgb. Rh negative mom + Rh positive
-Respiratory difficulty baby.
TTN S/S
NEC Prevention/Treatment Rapid respirations Conjugated vs. Unconjugated bilirubin
Prevention: Betamethazone and breast milk Grunting Bilirubin is yellow and is a product of the
Retractions breakdown of hemoglobin, which is the protein
Treatment: Nasal flaring inside red blood cells. If bilirubin cannot leave the
-Antibiotics Mild cyanosis body, it accumulates and discolors other tissues.
-Discontinuation of oral feedings
-Continuous or intermittent gastric suction TTN therapeutic management Unconjugated/Indirect: Toxic to the body. Fat
-Parenteral (IV) nutrition Oxygen if cyanosis present soluble breakdown of RBC. Combines with
-Surgery may be necessary with possible ostomy Gavage or IV feeding albumin and is carried to the liver, where it is then
conjugated.
Common Nursing Diagnoses Do not feed until supported on their own and RR
for Preterm Infants < 60 !!! Conjugated/Direct: Water soluble, so it can be
Activity Intolerance excreted through the kidneys.
Ineffective Airway Clearance Difference between RDS and TTN
Ineffective Infant Feeding Pattern RDS: insufficient surfactant, start to retain CO2 Physiologic jaundice
Ineffective Thermoregulation Normal phenomenon bc babies will lose their fetal
Risk for Disorganized Infant Behavior TTN: fluid in the lungs. give them time and RBC.
Risk for Impaired Parent-Infant Attachment oxygen support to get fluid out of the lungs.
Occurs >24 hours after birth. a build-up of
Asphyxia Meconium aspiration syndrome (MAS) bilirubin due to the normal hemolyisis of red blood
Lack of oxygen and increase of carbon dioxide in Develops when meconium in amniotic fluid enters cells that were needed for fetal circulation before
blood lungs during fetal life or at birth birth and discarded afterward
Results in ischemia to major organs (bc all
oxygen is just going to heart and brain) Occurs most often in asphyxia and term/post term Pathologic/Non-physiologic/Abnormal jaundice
infants who are SGA and have decreased Occurs WITHIN 24 hrs after birth. Related to a
Asphyxia possible causes amniotic fluid condition other than normal newborn bilirubin
-Insufficient surfactant being processed slowly by an immature liver.
Results in obstruction of airways. Alveoli can't Such conditions include an incompatibility
-Maternal factors: HTN, drug abuse, infection expand well, so the air can get in but can't get out between the baby's and the mother's blood types,
(like in TTN) "air trapping/barrel chest". Alveoli incompatibility of additional blood factors, or liver
-Placental factors: previa, abruption become overdistended and can burst = problems. There is actual pathology involved that
pneumothorax, might require more aggressive and lengthier
-Fetal factors: chromosomal abnormalities, cord intervention than physiological bilirubin problems.
compression, multiple births (one baby is hogging MAS s/s
nutrients), infection Tachypnea Total serum bilirubin rises more rapidly and to a
Cyanosis higher level than is expected and/or stays
Asphyxia s/s Skin stained yellow-green elevated for longer than normal.
 -Monitor for complications
Bilirubin Serum Levels & Phys Jaundice -Hypothermia
Jaundice becomes visible when bilirubin reaches -Hypotension Neonatal Abstinence Syndrome (NAS)
5-7 mg/dL. -Respiratory problems Disorder in which drug-exposed neonates
-Tachycardia demonstrate signs of drug withdrawal
If physiologic (normal) jaundice, bilirubin will begin -Glucose intolerance
to decline to <2 mg/dL by 5-7 days and then to -Lethargy NAS Characteristics
the normal adult level of 1 mg/dL by 10-14 days. -Feeding problems -Irritability, jittery
-Muscular rigidity/increased tone
Bilirubin Serum Levels & Non-Phys Jaundice Infection Treatment/Prevention -Restless
High risk zone: Bilirubin between 15-20 mg/dL. Treatment -Exaggerated Moro reflex
chart on p 454 in book -IV antibiotics -Prolonged high pitched cry
-Supportive care -Poor sleeping patterns
Pathologic/Abnormal Jaundice Complications -NVD, Weight loss
-Acute: bilirubin encephalopathy Prevention -Tachypnea, tachycardia
-Chronic: kernicterus -Infection control -Retractions
-Handwashing -Uncoordinated sucking/swallowing
Acute bilirubin encephalopathy
The acute manifestation of bilirubin toxicity. Hypoglycemia NAS Management
Blood-brain barrier has been impaired and -Can cause brain damage (glucose is the brain's - NAS scoring (see handout) If baby reaches a
unconjugated bilirubin has stained areas in brain. fuel/energy.) score of 24, will start meds.

Kernicterus -No consensus on exact level for hypoglycemia; - 50-60% need medications for withdrawal
The chronic and permanent result of bilirubin however, optimal glucose level approx. 50 mg/dL symptoms: oral morphine, tincture of opium,
toxicity. In this condition, unconjugated/free methadone, and phenobarbital; tapering dose
bilirubin deposits causing yellowish staining of the -Glucose levels reach the lowest point at 1-3
brain. hours after birth and begin to improve by 4-6 NAS Nursing Considerations
hours -Encouraging feeding
Mortality rate is 50%. -Cluster tasks-/cares
"Never Event" Hypoglycemia Risk Factors -Swaddling, prevent over stimulation
-Prematurity/Late Preterm -Infant/Postmaturity -Injury prevention: excoriations from itching and
If baby gets discharged and then comes back for -IUGR on butt from stools.
hyperbilirubinemia = BAD!! Probably kernicterus. -LGA/SGA -Enhancing parental attachment
-Asphyxia
Hyperbilirubinemia Management -Cold stress Gastroschisis
Promote excretion of bilirubin: frequent feedings! -Maternal diabetes (baby comes out with a lot of Congenital defect to the side of the abdomen,
Provide more protein to conjugate bilirubin. insulin on board, and now have low blood sugar) next to and not involving the cord
Prevent dehydration (via frequent feedings). Intestines protrude through defect and float freely
Hypoglycemia Early signs in amniotic fluid
Phototherapy: Helps convert billirubin. Can be -Jitteriness/Tremors
drying to baby, keep baby hydrated. Be sure to -Irritability Gastroschisis Management
cover eyes to prevent retina damage. Draw labs -Respiratory difficulty Gastric decompression
frequently. -Decrease in temperature IV nutrition
-Poor muscle tone Antibiotics
Exchange transfusions: Umbilical line to pull off -Poor feeding Surgical emergency, when stable
unconjugated bilirubin and mom's maternal
antibodies that are connected to RBCs, then give Hypoglycemia Late signs Infection prevention
baby more blood and albumin. Respiratory distress Injury prevention
Seizures
Infection Coma Gastroschisis Surgery
-Acquire infection before, during, or after birth Surgeons put mesh over organs, and each day
-10% infected during first month of life Hypoglycemia Prevention/Correction they roll it down to squeeze intestines back into
-Incidence in preterm infants 3-10x that of full Preventive measures include glucose monitoring stomach. In a few days, baby has normal belly
term infants and early feeds with bandage. Umbilical cord is not involved.
-Major cause of death during neonatal period --Screening every hour for 4 hours after birth and
then every 4 hours twice or until the results are TPN after surgery until you know intestines are
-Group B Streptococci: can cause severe normal working correctly.
meningitis --Glucose levels of less than 40-45 mg/dL
-Sepsis Neonatorum measured with a bedside glucometer should be Omphalocele
reported and verified by lab analysis Congenital defect in abdominal wall where the
Sepsis neonatorum intestines protrude into the base of the umbilical
GBS #1 Cause. Correction: If hypoglycemia persists despite PO cord
feeding, correction is with IV glucose infusion Associated with other anomalies (Trisomies)
Early onset - s/s by 24 hours of life acquired
during birth. Mortality 5-20% Infants of diabetic mothers Management - Similar to gastroschisis
-Neonatal mortality rate 5x that of non- diabetic
Late onset - develops after first week of life mothers Congenital Diaphragmatic Hernia (CDH)
acquired during or after birth, before or after -Congenital anomalies 3x more likely Hole in diaphgram.
hospital discharge. Mortality rate 5%. -4x more likely to be admitted to NICU
Diaphragm fails to fuse during gestation
Infection Risk Factors Infants of diabetic mothers complications
-Prematurity -Prematurity Large or small part of abdominal contents moves
-Low birth weight -Hypoglycemia into the chest cavity, usually on left side
-Rupture of membranes longer than 18 hours -Asphyxia
-Maternal infection; known maternal group B -Hypothermia/cold stress CHD Characteristics
streptococci -Respiratory distress -Small left lung because it didn't have room to
-Foul-smelling amniotic fluid -Birth trauma grow.
-Hyperbilirubinemia -Bowel sounds in chest, breath sounds in right
Infection Characteristics -Meconium aspiration -Barrel chest
-Low temperature is first sign bc baby is using up -Scaphoid (concave) abdomen
glucose and oxygen and other things to try and Infants of diabetic mothers Management -Mild to severe respiratory distress
keep themselves warm while fighting infection -Controlling maternal diabetes
and it's not working. -Glucose monitoring/early feeds CDH Management
-Mechanical ventilation A nurse is preparing to bathe a newborn and An assessment of Linda's beliefs and attitudes
-Gastric decompression: so that it's not putting observes a bluish marking across the newborn's about breastfeeding.
pressure on lungs & heart lower back. The nurse should understand that this
-Surgery when stable mark is Linda asks you why breastfeeding is so beneficial
-ExtraCorporeal Membrane Oxygenation frequently seen in newborns who have dark skin. for her newborn. You would want her to know
(ECMO)- breast milk has which of the following
A nurse is called to the birthing room to assist characteristics?
-Position infant on affected side to allow with the assessment of a newborn who was born It will provide immunity as well as nutrients for her
unaffected lung to expand at 32 weeks gestation. The newborn's birth weight newborn.
-Elevate head to decrease pressure on heart and is 1,100 g. Which of the following are expected
lungs findings in this newborn? The discharge coordinator is discussing some of
-Monitor respiratory status Lanugo the statements made by Linda. Which of the
Weak grasp reflex following would indicate she needs further
ECMO Translucent skin teaching about breastfeeding from you or one of
ExtraCorporeal Membrane Oxygenation your team members?
-Last resort A nurse is examining an infant who was just "While breastfeeding, I need to drink at least 12
-heart/lung bypass machine delivered at 41 weeks of gestation. Which of the glasses of fluid a day."
following characteristics indicates that this infant
-Veno-arterial: blood is drained from the venous is postterm? When teaching Linda about newborn feeding, you
system, oxygenated outside the body, and Leathery skin would include which statements to reflect safety
returned to the ARTERIAL system. and evidence-based practice?
-Veno-venous: blood is drained from the venous A nurse is caring for an infant who has a high Breastfeeding exclusively for 6 months can
system, oxygenated outside the body, and bilirubin level and is receiving phototherapy. reduce the risk of obesity later in life.
returned to the VENOUS system. Which of the following is the priority finding in this Maternal benefits of breastfeeding include a
newborn? decreased risk of breast and ovarian cancer.
Carotid Artery: at risk for stroke in the future since Sunken fontanels Once breastfeeding is established, pacifier use
it's plugged off. may help to decrease the risk of SIDS.
A nurse is caring for a newborn who is preterm
Myelomeningocele and has respiratory distress syndrome. Which of Linda's husband, Paul, plans to offer their baby
-Most common form of spina bifida cystica the following should the nurse monitor to evaluate bottled breast milk once daily when Linda returns
the newborn's condition following administration to work. Educational literature available on the
-Protrusion of a membrane-covered sac through of synthetic surfactant? unit should include which guideline?
the spina bifida (incomplete closure of spine) Oxygen saturation After the baby drinks from a bottle, he should
discard any milk still in the bottle.
-Sac contains meninges, nerve roots, spinal cord A nurse is caring for a newborn who has
and spinal fluid suspected neonatal abstinence syndrome? Which A mother who intends to breastfed is advised by
of the following findings supports this diagnosis? her sister to use formula for the first few days until
-Increased alpha-fetoprotein Continuous high-pitched cry her "real" milk comes in. Which is the nurse's best
response regarding this information?
Myelomeningocele: Paralysis Baby Atkin's father plays in a garage band for a Discuss that colostrum is all the nutrition a baby
Depends on where myelomeningocele is located. hobby, and his mother enjoys knitting. Your care needs the first few days of life.
team has agreed to design a developmental care
Monitor lower extremities environment for Baby Atkins that will both make Newborns can become dehydrated easier than
Look for dribbling of urine or stool him feel secure and help his parents interact more adults. This is explained by which statement?
Monitor for ICP with him. Which would be the best action for your The large amount of body fluids are mainly
team to take? extracellular fluid in a newborn.
Myelomeningocele Prevention/Management Arrange a blanket Mrs. Atkins has knit into a circle
Prevention: Maternal folic acid or "nest" for the baby. A mother planning to bottle feed asks you which
form of formula is the most economical to use.
Mngmnt: Baby Atkins has surfactant administered at birth. Which of the following would you include in your
-Surgery to correct defect as soon as possible When Mrs. Atkins asks you why her baby had to response?
-Antibiotics receive surfactant, what would be your best The powder type, which is combined with water.
-Long-term follow up response?
-Prevent injury "Surfactant keeps his tiny lung sacs open and this A newborn was resuscitated at birth due to poor
-Monitor for signs of infection improves his breathing." respiratory effort. Which assessment data would
-Monitor for increased intracranial pressure concern the nurse the most at 6 hours birth?
Baby Atkins is at risk for having apnea and Body temperature of 98.0 F
A nurse is caring for a newborn who was born at bradycardia. What initial nursing intervention
38 weeks of gestation, weighs 3,200 g, and is in should you initiate during these events to maintain A nurse has been assigned to the care of two
the 60th percentile for weight. Based on the his vital signs in a safe range? newborn infants who are 38 weeks gestation. One
weight and gestational age, the nurse should Gently flick the sole of his foot to stimulate the is small-for-gestational-age and one is large-for-
classify this neonate as baby to breathe again. gestational-age. The nurse knows that they both
appropriate for gestational age. are most likely at risk for all of the following
You are concerned that Baby Atkins will develop complications except
A nurse is completing a newborn assessment and hyperbilirubinemia because of his immaturity. Intraventricular hemorrhage
observes small white nodules on the roof of the Because the prevention of jaundice is one of your
newborn's mouth. This finding is a characteristic NICU's quality indicators, what priority nursng In the delivery of an infant with meconium stained
of which of the following conditions? intervention would you initiate to best prevent fluid, the nurse should anticipate which measure
Epstein's pearls hyperbilirubinemia in Baby Atkins? being taken first?
Urge all mothers to breastfeed early to promote Bulb syringe used to suction mouth and nose
A nurse is assessing the reflexes of a newborn. In infants' bowel motility. before delivery of shoulders.
checking for the Moro reflex, the nurse should
perform which of the following? Mrs. Atkins asks you why the baby in the Why do we worry about migraine HA as a
Hold the newborn in a semisitting position, then incubator next to her baby whose other has condition that can cause complications?
allow the newborn's head and trunk to fall diabetes mellitus was fed so soon after birth. Why She can have a stroke, if we increase her blood
backward. is it important for infants of diabetic women to be volume she can have a seizure because she has
fed early? HTN
A nurse is completing an assessement. Which of This helps prevent rebound hypoglycemia from
the following data indicate the newborn is occurring. Why do we worry about abnormal pap smears?
adapting to extrauterine life? Preterm labor or an incompetent cervix (cerclages
Apnea for 10-second periods A nursing assessment of Linda Satir's plan for her sew cervix closed)
Obligatory nose breathing infant's nutrition should begin with which of the
following? What are the two types of 3rd trimester bleeding?
Abruptio placenta Placenta Previa - ..where it encroaches on the
Placenta previa internal os and may cover a portion or all of os. What are the 5 hypertensive disorders in
As cervix dilates and effaces, placental pregnancy?
What is the premature separation of placenta attachment is disrupted and bleeding occurs Gestational HTN
from uterine wall that occurs before 3rd stage of Preeclampsia
labor? Why is mag sulfate given to a mother 24 hours Eclampsia
Abruptio placenta before a premie is to be delivered? Chronic HTN
To reduce incidence of cerebral palsy (brain Preeclampsia superimposed on Chronic HTN
What is the most common cause of serious protectant)
vaginal bleeding? Gestation HTN: increased BP after mid
Abruptio placenta If a mother has a complete previa, what do you pregnancy (20 weeks), with or without
need to explain to her? proteinuria?
Bleeding + pain = _________ Placenta She needs to have a c/s because we don't want WITHOUT
Abruptio her dilating probably at 36 weeks. We need to
check fetal lung maturity by and amnio or l/s ratio. Preeclampsia: Pregnancy specif after 20 weeks:
No pain + bleeding = Placenta _________ If she's dilating you need to tocolyze her to stop gestational, with or without proteinuria?
Previa WITH
If a pt presents to triage with vaginal bleeding,
What is the most common cause of increased risk should you assess her cervix? Eclampsia: Preeclampsia with what?
of placenta abruptio? No, she will have U/S to determine placenta Preeclampsia (increased BP after 20 weeks with
Hypertension location proteinuria) and SEIZURES

Why can the premature ROM increase risk for What increases the risk for placenta previa? A mother has a BP of 165 and trace protein,
Abruptio Placenta? Endometrial scarring (previous placenta previa, should you be concerned?
The uterus is overdistended with fluid and previous TAB, closely spaced pregnancies, No
collapses, sometimes causing the compressio of previous c/s, Decreased blood flow to
uterine muscels and the placenta is scrunchin in endometrium, increased placental mass (multiple what are cardiovascular effects of HTN?
on itself and can start to peel off pregnancy) Increased capillary permeabiliy (edema to general
areas, hands/face, cerebral [seizures],
Uterine fibroids are fed by what and can get What can cause decreased blood flow to the pulmonary)
bigger during pregnancy? endometrium?
Placenta Abruptio HTN, diabetes, uterine tumor, drug use (cocaine), What are the lab value changes associated with
cigarette smoking, AMA the cardiovascular effects of HTN?
What are the s/s of abruptio? -Decreased serum albumin
-sudden onset of intense localized uterine pain What are the s/s of placenta previa? -Increased hct d/t hypovolemia
(abdominal, or low back pain) PAINLESS, BRIGHT red bleeding -Coagulopathy (decreased plts)
-vaginal bleeding In active labor, uterus relaxes between
-board like abd that is tender contractions What are the cerebral effects of HTN in
-fetal distress Fetal malpresentation - Transverse or unengaged pregnancy?
-maternal symptoms of hypovolemic shock fetal presenting part is common -Decreased blood flow and edema (Hyperreflexia
[+3, +4 clonus), HA, visual disturbances [blurred
What color is thet bleeding of placenta abruptio? How is placenta previa dx? vision], irritability, seizure, CVA [strokes],
dark U/S epigastric pain->enlarged liver)

How does abruptio affect contractions? A 36 wk marathon runner and expectant mother What are the renal effects of HTN?
can be ineffective or occurring too rapidly has low lying marginal placenta previa, tell her -Decreased renal perfusion (decreased GFR-
what? >decreased UO, tubular reabsorption more
How does abruptio show on the fetal heart strip? She needs to go on bed rest, no vaginal exams or efficient [edema], increased adh, corticosteroids,
Hyperactivity of the fetus, then decreased activity intercourse aldosterone, proteinuria)
and loss of FHR variability and if continues loss of
FHR Can a woman with low lying/marginal placenta Why does proteinuria occur?
previa have a vaginal delivery? increased protein is lost in urine secondary to
What do you need to prepare mother for with a Yes, if placental disruption is not pronounced, she degerative glomeruli changes (damage to kidney)
mild abruptio? has reassuring fetal indicator and if her placenta
Induce labor and vaginal delivery is greater than 2 cm for os What are the associated lab changes of HTN
Kleihauer-Betke (KB) test (renal)?
IV (largest gauge possible) - bc of increased risk A woman is dx'ed with complete or partial Proteinuria
of DIC placenta previa, should you give her a vaginal Increased BUN
evaluate clotting exam? Increased creatinine
Type and cross match blood No, need to know where the placenta is. if her
Hospitaliz and monitor maternal bleeding and sx's bleeding is profuse and is >36 weeks gestation, What are the hepatic effects of HTN?
of labor mature L/S ratio or PG present, immediate Edema and decreased hepatic perfusion (liver
Monitor FHR delivery. enlargement, epigastric pain, NV, liver rupture if
Administer betamethasone to stimulate fetal lung severe)
maturity If there is bleeding in the 3rd trimester, what do
you need to wait for before doing a vag exam? What are the associated hepatic lab value
What does a positive KB test indicate? U/S dx, if not available speculum exams can be changes?
There is fetal blood in mom's circulation done under "double set-up" Increased liver enzymes if HELLP syndrome
Increased bilirubin (severe pre-eclampsia or with
What does a negative KB test indicate? Placenta _______: chorionic villi attach directly to HELLP)
-no blood in circulation but still give Rh if Rh myometrium
negative mother Accreta What are the uterine and fetal effects of HTN?
Decreased uterine blood flow (vasoconstriction,
What is the tx for SEVERE abruptio &/or fetal Placenta _______: myometrium is invaded increased vascular resistance, decreased
distress? Increta circulation to placenta, fetal hypoxia [IUGR,
-Monitor volume status of mother hypoxia, demise])
-Restore blood loss quickly Placenta _______: Myometrium is penetrated -
-Continuously monitor fetus sometimes into bladder and intestines What are the S/S of HTN?
-Correct coagulation defect if present Percreta - typically have to have a hysterectomy Traditional triad
-Expedite delivery (prepare for C/S) -HTN
What is the leading cause-specific cause of -proteinuria
Placenta _______: implantation of placenta in maternal death? -edema (not dx but a warning) (sudden, excessive
lower uterine segment Hypertensive disorders weight gain - different from ladies with pedal
edema, usually see periorbital, marked edema of Treat S/S and deliver Phototherapy for infants with pathological
face, hands, lower abdominal, severe generalized Sedatives prn jaundice
edema with ascites) AntiHTN - hydralazine Posssible exchange transfusion
Magsulfate
What are the danger sx's of disease progression Liver and kidney labs, hct What is direct coombs test for?
of HTN? NST, AFI, fetal activity done on fetal blood to identify maternal antibodies
Visual disturbances (spots before eyes), HA that Lung maturity test, if fetus is preterm attached to fetal RBC's
wont go away with tylenol rest or fluids,
hyperreflexia (4+ clonus), What does mag sulfate do? What do we recommend for jaundice babies?
epigastric pain, decreases the amt of ach produced by motor Babies who have jaundice we want to encourage
NV, nerves and thus blocks neuromuscular feeding and we'll put under the bililight. We want
hemoconcentration, transmission them to eat so they can poop and pee and get rid
oliguria (<30cc/hr), of extra bilirubin.
seizure What indicates magsulfate toxicity?
R<12 Why do blood type o mothers develop antibodies
What are the indicators of MILD preeclampsia? No DTR's against A, B, or AB babies?
-BP: >140/>90 x2 4-6 hours apart Decreased LOC through foods and exposure to bacteria. As a
-Proteinuria >1 +(>30mg/dL) result, some women have high titers before they
-Reflexes normal What is the normal level of mg? become pregnant.
-Liver enzymes normal or increased minimally 1.5-2.4 mEq/L Maternal blood antibodies cross placenta to fetus
-Plts normal producing fetal blood cell hemolysis
-No thrombocytopenia yet What is the therapeutic level of mag?
Brisk reflexes are bad, need to watch her 4-7.5 Typically, mom is type O and she has a baby that
is A, B, or AB. These babies have a higher
If clonus and reflexes are abnormal you need to A magnesium lvl of _-_ implies loss of DTR's chance
decrease what? 10-12 of the AB incompatibility and they're more at risk
stimulation 15= respiratory paralysis for jaundice. We'll typically keep them for a little
longer and we'll do a bili on them before they go
What BP indicates severe preeclampsia? If a woman has a mag level of 10, what would you home. If that's elevated we're gonna do a
>160/>110 x2 or more give her to reverse this? transdermal bili and if that's elevated, they'll need
Calcium gluconate a blood draw to make that determination.
What proteinuria indicates severe preeclampsia?
3+ to 4+ or 24 hr urine protein of >2-3 g or more, If mag levels are greater than 7, worry about How does ABO incompatibility differ from Rh
5g indicates immediate delivery! what? incompatibility?
pulmonary edema - assess respiratory status -ABO can occur during the 1st pregnancy
What labs indicate severe preeclampsia? -Does not necessarily increase in severity with
Elevated hc, serum creatinine, uric acid, & liver If you have a 28 weeker that has PIH and is on subsequent pregnancy
enzymes, <100,000 plts magsulfate, why is she being given this? -Does not require prenatal treatment
to decrease her risk of seizing -Seldom needs post delivery treatment
If a pt has <100,000 can they get an epidural?
No, they might bleed out Why would a c/s mother that was on mag sulfate, What is the tx for ABO incompatibility?
and now on PP still get mag sulfate? Blood titers during pregnancy to anticipate
A hyperreflexia of greater than _+, and possible Magsulfate is a smooth muscle relaxant, you problems after birth
clonus indicates severe preeclampsia? worry about hemorrhaging Cord blood group and Coombs
3+ also see oliguria of less than 20 ml or <400- Phototherapy for infants with pathological
500 ml in 24 hours The Rh- gene is ? jaundice and increase feedings
homozygous
Eclampsia is characterized by what? Preterm labor is labor that occurs prior to how
Grand mal seizure An Rh- mother should get Rhogam at how many many weeks?
weeks? 36.6 weeks
______: progression of severe preeclampsia that 28 weeks and again after the baby is born to save
show sx's of hematologic conditions inv. liver her next baby Preterm labor is responsible for ___ of infant
HELLP syndrome morbidity and death, especially if born before 28
Explain Rh isoimmunization weeks.
What does HELLP stand for? A mother that is Rh- who has her first Rh+ baby 2/3rds
Hemolysis will develop antibodies towards that baby. The
Elevated Liver Enzymes first baby will be fine. The second baby, if Rh-, will How long should a cervix be?
Low Pls be attacked by the mothers antibodies and lysing 3-4cm long. do u/s to see if it's shrinking
of the baby's RBC's will occur
With the help syndrome, what sx's will you see? What are the medical factors leading to preterm
anemia and jaundice When do we blood type a mother? labor?
elevated ALT and/or AST, epigastric pain, NV 1st prenatal visit Renal dx; UTI
thrombocytopenia, abnormal bleeding and cloting Peridontal disease - more likely to have sepsis in
time, and possible DIC If mother is Rh-, the antibody screen (indirect addition
Coombs) will detect what? anemia
Why is DIC a possibility? prior sensitization Chronic hypertension
small clots are using all the clotting factor and
then the placenta comes out and she will Do you need to give an Rh- mother, rhogam afte What are the social/behavior factors that lead to
hemorrhage. rmiscarriages, TABs, amniocentesis, abdominal preterm labor?
We can't replace blood as fast as she's bleeding trauma, external cephalic version? race other than Caucasian*
YES age <17 or >35
What is the MEDICAL management of mild inadequate prenatal care
preeclampsia? Rhogam should be given within how many hours low SES
Bedrest on L side postpartum? prepregnant weight <100 lb*
Balanced diet (moderation in fat and salt) 72 hours domestic violence
NST, U/S AFI and fetal movement, KC at 28 smoking, alcohol, substance abuse
weeks What test on maternal blood determines whether psychological distress
Lab Tests (liver, kidney, hct, plts) the RH-negative client has developed antibodies
to the Rh antigen? What are the S?S of preterm labor?
What is the MEDICAL management of severe Indirect Coombs -6 or more contractions 1 or more hrs (painful or
preeclampsia? not)
Deliver if maternal or fetal status deteriorates or if What is newborn therapy for Rh isoimmunization? -low abdominal cramping/menstrual-like cramps
term c/s may e necessary if pt not stable Cord blood group and coombs -dull, intermittent backache
-suprapubic pain or pressure IV replacement of fluids and electrolytes. Small
-pelvic pressure _________ abortion: Cramping and bleeding, frequent meals.
-increased vag discharge or rupture of cervix is dilated, may have ROM, esp in early
membranes pregnancy. Hyperemesis gravidarium nursing interventions:
Inevitable - Can't prevent. E.g. dilated cervix at 10 -Education, accurate recording of volume and
A positive fetal fibronectin test indicates? weeks. frequency of vomiting.
Woman may go into labor and needs to be -Daily weights and I/O
observed for 24 hours _______ abortion: pt may have bleeding, -Education re small frequent meals, no greasy
cramping & expulsion of part of products of foods. Sips of liquids.
What are the conditions under which attempts to conception but not all of it. Tissue remains in -Fetus at risk for IUGR, hypoxia and ketoacidosis.
STOP labor are justified? uterus, patient is at risk for hemorrhage.
-membranes intact (prevents infection) cervix <3 Incomplete Cervix is not dilated & the placenta is still
cm or <50% effaced attached to the uterine wall, but some bleeding
-no fetal distress ______ abortion - pt has bleeding, cramping and occurs.
-no medical/obstetric condition to contraindicate expulsion of products of conception. Threatened abortion
(e.g. chorio or severe hypertension) Complete. Everything done nothing in uterus.
Placenta separated from the uterine wall, cervix
How do we control preterm labor ______ abortion: decreased s/s of pregnancy, has dilated, & the amount of bleeding has
pharmacologically? fetus has died in utero, no expulsion, at risk for increased
Bed rest a common therapy DIC. Imminent
IV hydration Missed. No bleeding - just dead fetus
MgSO4(smooth muscle relaxant..Ca antagonist) The embryo/fetus has passed out of the uterus;
IV Incompetent ______ - a defect r/t trauma of the however, the placenta remains.
Terbutaline cervix or congenitally short cervix Incomplete
Nifedipine (CCB) cervix
Indocin The most common site for ectopic pregnancy is
What are the risk factors for an incompetent where?
Terbutaline is contraindicated in? cervix? fallopian tubes - "tubal pregnancy"
diabetes - interferes with glucose metabolism Surgery on cervix
D&C Why is a tubal pregnancy dangerous?
When do you need to hold terbutaline? previous deliveries Because as the fetus grows, the tube can actually
HR >120 DES exposure explode or tear. Mom and baby can die, mom can
hemorrhage. We cannot save babies in tubal
Terbutaline is given __ How does an incompetent cervix manifest? pregnancies. We can't counsel her that we can
IV, NOT IM Cervical dilatation WITHOUT painful contractions. save her baby. She needs to terminate the
Membranes rupture, labor begins and preterm pregnancy because she will die.
How do you know terbutaline is working? delivery of infant
increased HR What does TORCH stand for in TORCH?
What is tx for an incompetent cervix? Toxoplamosis
With mag sulfate, monitor for what? Cerclage: purse-string suture that encircles the Other infections
Loss of deep tendon reflexes, urine output <25-30 internal os. Rubella
ml/hr. Respiratory depression, 12/min. Pulmonary Cytomegalovirus
edema What is the nursing education for an incompetent Herpes simplex
cervix?
Hold Nifedipine (a CCB) if BP SBP is less than? Education. Rest post insertion. No intercourse, What is TORCH for?
80/50 [Sharp MV - SBP<85] nothing in vagina. Will be removed prior to This is a blood test we do on moms because we
delivery. have a baby with some kind of deformity or
How does indocin work? problem and we can't figure out what's wrong with
it inhibits prostaglandin synthesis-->inhibiting Gestational Tropoblastic Disease is defined as: her. We'll check for TORCH and keep an eye on
uterine contractions An abnormal proliferation of the placenta - the baby.
hydatidiform moles, gestational trophoblastic
Indocin may cause premature closure of what? neoplasia. T - Toxoplasmosis
ductus arteriosis-->we need ductus arteriosus in RF Consumption of raw or uncooked meat or
utero. use of indocin usually doesn't exceed how Assessment of Gestational Tropoblastic Disease: handling of cat feces
many hours?. 48. Use if greater than 32 weeks U/S reveals no fetus S/S: Maternal mild flu symptoms.
gestation Elevated HCG levels
Exaggerated symptoms of Pregnancy O - Other infections
Betamethasone IM given if viable and < 34 wks Early symptoms of PIH RF: varies (example: hepatitis, listeria, syphilis
Corticosteroid--> increases surfactant production S/S: varies
in fetal lungs What are the complications of Gestational
Peak effect in 48 hrs after giving & lasts 7 days Tropoblastic Disease? R - Rubella
Infection RF non-immunized
What assessment would you make of the PROM? DIC S/S: fever, rash and mild lymphedema
Gush of watery fluid, not color, nitrazine paper Possible Choriocarcinoma
blue (alkaline) urine is acidic doesn't change the C- Cytomegalovirus
color. Ferning pattern What is the tx for Gestational Tropoblastic RF Droplet infection
Disease? S/S: Asymptomatic or mild mononucleosis
PROM puts the infant at risk for what? D&C symptoms
prolapsed cord Weekly Serum HCH levels until negative
Patient should not become pregnant for a year H - Herpes simplex Virus
What is the nursing care for preterm premature RF: lesions
rupture of membranes? Hydatidiform mole. A common sign is... Obtain cultures on women with HSV near term.
Monitor fhr vaginal bleeding, often brownish (the C/S recommended for mothers with active
Vitals q 2 hours characteristic "prune juice" appearance) but lesions.
Avoid exam (vaginal) sometimes bright red
Monitor for contractions what is the nursing goal with high risk pregnancy?
Monitor for signs of CHORIOANMIONITIS. What is hyperemesis gravidarium? healthy term infant and mother
Obtain vaginal culture for GBS Vomiting during pregnancy that results in
dehydration and electrolyte imbalance. thought to what are some conditions or risks of pregnancy?
______ abortion: Patient has vaginal bleeding, be due to Increase HCG. obesity
may have cramping back pain, no cervical substance abuse
dilatation How do you tx hyperemesis gravidarium? diabetes
Threatened anemias
bleeding malformations of skeletal and major organ intense fetal surveillance
hypertension systems potential hospitalization
infection
what is the true danger of opioids? what are some ways to monitor the mother during
what is one of the most important ways to prevent withdrawal after birth pregnancy with diabetes
gestational complications? fingerstick
making sure the mother is healthy and living a what are the dangers of withdrawal to a fetus? urine check for proteins or nitrates
good lifestyle before pregnancy fetal hypoxia which causes urine check for ketone
spontaneous abortion check kidney function
what factors are associated with low BMI placental insufficiency eye exam
mothers? hypertensive emergencies monitor blood glucose trends with HbdA1c
IUGR, preterm birth, iron deficiancy anemia preterm labor
IUGR what is the corner stone of treatment for GD
what factors are associated with high BMI fetal death diet
mothers?
infertility, gest. diabetes and hypertension, birth what are some other dangers of opioid abuse to why do we worry about GD?
defects, large infant, prolonged labor, postpartal fetus? insulin levels can be hard to control, esp if
anemia repeated cycles of intoxication and withdrawal vomiting
unstable environment and insufficient nutrients increased caloric needs may rapidly decrease
what are some things more likely to affect after birth
mothers who were obese before pregnancy? what is the recommended treatment for
gain more weight and keep it on substance abuse? how do we screen pregnant women for GD?
high risk of diabetes methadone maintenance and psychosocial 24-28 weeks check for previous GD, family
support history of diabetes
what are the major risks in pregnancy? comfort measures marked obesity
substance abuse breastfeeding may reduce symptoms? multiple pregnancies
preeclampsia
gestational diabetes what are the benefits or methadone maintenance treatment for GD?
bleeding and psychosocial support? test for increased blood glucose
preterm labor 3x less less opioid use keep blood glucose and insulin in balance
infections increases prenatal care diet and exercise
3x less risk of low birth rate teach about condition and mgt
what are some facts associated with substance mother more likely to keep child may need insulin
abuse>
most frequently missed diagnosis classifications of type one diabetes when do you do an ultrasound for a baby with GD
normally have no prenatal care absolute insulin deficiency 18 weeks and 28 weeks
tend to be non compliant
just show up for labor and delivery classification of type two diabetes how often do you monitor fetal activity after 28
nurses dont ask the right questions insulin resistant or deficiency weeks?
daily
general physical signs of substance abuse? prediabetes
dilated, constricted pupils impaired fasting glucose when do you do nonstress testing for fetus with
inflamed nasal mucosa GD
needle tracts pregestational diabetes 28 weeks
poor nutrition either type 1 or type 2
slurred speech what screening do you do for a fetus with GD at
odor of alcohol gestational diabetes 16-20 weeks
any degree of glucose intolerance with AFP to check for neuro tube defects
behavioral signs of substance abuse? recognition during pregnancy
memory lapses what drugs can you not use during labor with GD
mood swings maternal risks with gestational diabetes? and why?
hallucinations increase in amniotic fluid drugs to stop labor because they interfere with
frequent accidents difficult labor with large baby glucose control
signs of depression or agitation ketoacidosis
suicidal retinopathy how often do you check glucose levels during
labor with GD
what are some prevention efforts to reduce what is hydramnios? every hour
alcohol abuse> increased amniotic fluid
find out the fathers role in helping the mother what IVs do you need started with GD labor
abstain from alcohol use what are some congenital abnormalities that can 2 started, one with insulin and one without
avoid social situations that involve drinking effect neonates with GD?
target women who may become pregnant as well cardiac defects what helps control diabetes after labor?
as pregnant women central nervous system breastfeeding
skeletal defects
fetal alcohol syndrome is the leading known what specific teaching do you need to give these
cause of what in infants? other causes of neonatal morbidity with GD? mothers?
mental retardation RDS- no enzymes for surfactant production diet control
can cause serious social and behavioral problems polycythemia- cannot delivery 02 glucose monitoring
hyperbilirubinemia- immature liver enzymes symptoms of hypoglycemia
which drug causes the most damage to babies? no smoking
alcohol plan of care for families antepartum travel and diabetes
diet and exercise support groups
fetal alcohol syndrome monitor blood glucose increased risk for C section
facial abnormalities and growth retardation urine testing
insulin therapy if diet isnt working what is the most common medical complication of
fetal alcohol effect fetal surveillance pregnancy?
some abnormalities but not diagnoses with FAS iron deficancy anemia
what are ways to cut risks for pregnant women
alcohol related neurodevelopment disorder who are diabetic? how can you prevent IDA
functional or mental impairments linked to frequent prenatal visits 30 mg a day supplement
prenatal exposure dietary restrictions
self monitoring blood glucose how much supplement do you give if anemic?
alcohol related birth defects frequent lab tests 60-120 mg a day
 scanty or profuse 140/90
what is a side effect of iron? no vaginal exams
constipation severe preeclampsia
abruptio placenta 180/110
what are some clinical manifestations of anemia? premature seperation of placenta oliguria
fatigue prior to birth during labor process cerebral or visual disturbances
weakness emergency pulmonary edema
malaise epigastric pain
anorexia ectopic pregnancy impaired liver function
susceptibility to infection implantation outside of the uterus thrombocytopenia
pale mucous membranes lower abdominal pain to goes to the shoulder fetal growth restriction
tachycardia must get help
abnormal labs which side do you sleep on for preeclampsia
treatments for ectopic pregnancy? left
how do you prevent folic acid deficiency? surgery if ruptures
supplement with 0.4 mg a day methotrexate - inhibits cell growth of the enbryo what is magnesium sulfate
coexists with iron deficiency so supplement both monitor hCG levels CNS depressant

sickle cell anemia gestation trophoblastic disease signs of MS toxicity

folic acid supp 1.0 a day group of tumors grow inside of the uterus that depressed reflexes
teat promptly start as cells that would grow into the placenta oliguria
close observation and eval of symptoms during pregnancy confusio
uterine enlargement will be faster than normal resp depression
thalassemia elevation of hCG circ collapse
mistaken for iron deficiency anemia
folic acid supplements what causes a role in hyperemesis gravidarum? what is the MS antidote
genetic diagnosis hCG calcium gluconate

what do we do if bleeding occurs during treatment? What happens to the body during Rh
pregnancy hydration with lactated ringers sensitization?
monitor bp and pulse restore electrolyte balance Hemolysis caused by maternal IgG antibodies in
count and weigh pads phenergen fetus which causes fetal anemia, increased RBC
signs of shock production
if 12 weeks, check FHR what does preeclampsia increase risk of?
prep IV and equip for exam future cardiovascular and metabolic disease in do you want a negative or positive coombs test?
have o2 ready women negative means that no sensitization has occured
prep for type and crossmatch
when does preeclampsia normally occur? RhoGAM administration
signs of shock after 20 weeks within 72 hours
pallor destroys fetal cells in maternal circulation before
clammy skin ecclampsia sensitization
perspiration occurance of seizure in woman with preeclampsia
dyspnea that cannot be contributed to another cause How much medication to HIV infected women
restlessness severe headaches receive?
hyperrelexia triple therapy of antiretroviral drugs
complete abortion
all expelled chronic hypertension group b strep
present before pregnancy or diagnoses before 20 test at 35-27 weeks
missed abortion weeks gestation give antibiotics at least 4-6 hours before delivery
fetus dies in utero but not expelled
what occurs in women and fetus pathologically what can be responsible for fetal congenital
threatened abortion during pregnancy with hypertension? malformations during first trimester or pregnancy?
unexplained bleeding ... lack of glycemic control before contraception

septic abortion how do we care for women with preeclampsia? maternal insulin with what as pregnancy
infection increased monitoring progresses? why?
patient education increases because of placental hormones and
recurrent pregnancy loss administration of magnesium sulfate cortisol creating increased insulin resistance
3 or more antihypertensives
corticoid steroids- increase fetal lung maturity what are the leading cause of maternal and
what are a majority of first trimester abortions perinatal morbidity and mortality?
related to? HELLP syndrome hypertensive disorders
chromosomal abnormalities hemolysis
elevated liver enzymes what are the two types of hydatidiform mole?
what are some other causes? low platelet count- best indicator complete and partial
faulty implantation associated with preeclamp
weakened cervix how is HM diagnosed?
chronic disease signs and symptoms of HELLP beta hCG titers are measured
acute infection nausea
cocaine malaise how are premature separation of placenta and
epigastric pain placenta previa differentiated?
what are the indications of spontaneous abortion? upper quadrant pain type of bleeding
cramping edema uterine tonicity
backache hyperbilirubinemia presence or absence of pain
diagnosed by ultrasound lab data
Syphilis
treatment to incomplete abortion? risks with HELLP S/S:
Dilation and Curettage placental abruption -Stage 1: Painless chancre disappears within 4
RhoGAM preterm birth weeks
suction perinatal mortality -Stage 2: Copper-colored rash on palms and
sedated at birth soles; Low-grade fever
placenta previa -Stage 3: Cardiac and CNS dysfunction
painless bleeding mild preeclampsia Transmission:
-Mucous membrane or skin factor in morbidy & mortality), Kaposi's sarcoma a) Do nothing because the client's sexual habits
-Congenital; Kissing; Sexual contact (Most common malignancy) place him at risk for contracting other STDs.
Nursing: Transmission: b) Educate the client about why it's important to
-Prevention-condom -Contaminates blood or body fluids, sharing IV inform sexual contacts so they can receive
-Treat with penicillin IM drug needles, treatment.
-Reportable disease -Sexual contact, Transplacental & possibly c) Inform the health department that this client
-Sexual abstinence until treatment complete through breast milk contracted an STD.
Nursing: d) Inform the client's sexual contacts of their
Gonorrhea -No effective cure; Antiviral agents (zidovudine, possible exposure to chlamydia.
S/S: acyclovir) are being used to slow the progression B) Educate the client about why it's important to
-Both- Thick discharge from vagina or urethra -Contact precautions inform sexual contacts so they can receive
-Females: Frequently asymptomatic, if not -Nutrition- High protein and calories treatment.
symptoms are purulent discharge, dysuria, and -Teaching: The nurse should educate the client about the
painful intercourse Behaviors to prevent transmission: safe sex, not disease and how it impacts a person's health.
-Male: Dysuria, yellow-green discharge sharing toothbrushes, razors etc. Further education allows the client to make an
Transmission: Measures to prevent infection: good nutrition, informed decision about notifying sexual contacts.
-Mucous membrane or skin hygiene, rest, skin and mouth care, avoid crowds The nurse must maintain client confidentiality
-Congenital; unless law mandates reporting the illness;
-Vaginal, Orogenital, Anogenital sexual activity A nurse is teaching a client with genital herpes. contacting sexual contacts breaches client
Nursing: Education for this client should include an confidentiality. Doing nothing for the client is
-Treatment: IM ceftriaxone & PO doxycillin; explanation of: judgmental; everyone is entitled to health care
azithromycin a) why the disease is transmittable only when regardless of his health habits.
-Monitor for complications: Pelvic inflammatory visible lesions are present.
disease b) the need for the use of petroleum products. A nurse is teaching a health class to a group of
c) the option of disregarding safer-sex practices clients likely to be at highest risk for gonorrhea.
Genital Herpes (HSV-2) now that he's already infected. What is the age range of the clients?
S/S: d) the importance of informing his partners of the
-Painful vesicular genital lesions disease. a) 60 to 70 years
-Difficulty voiding D) Importance of informing his partners of the b) 15 to 24 years
-Recurrence in times of stress, infection, menses disease. c) 25 to 29 years
Transmission: Clients with genital herpes should inform their d) 30 to 45 years
-Mucous membranes or skin partners of the disease to help prevent B) 15 to 24 years
-Congenital transmission. Petroleum products should be Gonorrhea is the second most frequently reported
-Virus can survive on objects such as towels avoided because they can cause the virus to communicable disease in the United States. Its
Nursing: spread. The notion that genital herpes is only highest incidence occurs in the 15- to 24-year-old
-Acyclovir (not cure) transmittable when visible lesions are present is age group.
-Emotional support, Sitz baths false. Anyone not in a long-term, monogamous
-Local medication relationship, regardless of current health status, A 16-year-old patient comes to the free clinic and
-Client must notify sexual contacts should follow safer-sex practices. is diagnosed with primary syphilis. The patient
-Monitor pap smears on regular basis-increased states that she contracted this disease by holding
incidence of cervical cancer Katrina Sterrett, a 26-year-old preschool teacher, hands with someone who has syphilis. What is
-Precautions- vaginal delivery is being seen by a physician who is part of the the most appropriate nursing diagnosis for this
internist group where you practice nursing. She is patient?
Chlamydia undergoing her annual physical and is having
S/S: many lab tests done as a condition of her a) Alteration in comfort related to impaired skin
-Female: May be asymptomatic; thick discharge employment and upcoming wedding. She is integrity
w/ acrid odor, pelvic pain, yellow-colored returning for her results and is devastated to learn b) Fear related to complications
discharge; painful menses that she has the sexually-transmitted infection, c) Noncompliance with treatment regimen related
-Male: Dysuria, frequent urination, watery gonorrhea. What would contribute to her to age
discharge ignorance of her condition? d) Knowledge deficit related to modes of
Transmission: a) Being asymptomatic transmission
-Mucous membrane; Sexual contact b) All options are correct D) Knowledge deficit related to modes of
Nursing: c) Being sexually inactive transmission.
-Notification of contacts d) Knowing the signs and symptoms of STIs Syphilis is spread mainly by sexual contact and
-May cause sterility A) Being asymptomatic may be congenital. The patient displays
-Treatment: azithromycin, doxycycline, Many women who have gonorrhea are knowledge deficit about the modes of
erythromycin asymptomatic, a factor that contributes to the transmission for syphilis.
spread of the disease.
Condylomata acuminata (Genital warts) A 22-year-old patient has presented to her
S/S: Within the free clinic where you practice nursing, primary care provider for her scheduled Pap
-Initially single, small papillary lesions spreads you hold weekly sexual education classes open to smear. Abnormal results of this diagnostic test
into large cauliflower cluster on perineum and/or the public. Within the classroom, you may imply infection with:
vagina or penis communicate the CDC's numbers for the
-May be itching/burning incidence of STIs and their impact upon public a) human papillomavirus (HPV).
Transmission: health. Which is the fastest-spreading bacterial b) Chlamydia trachomatis.
-HPV; Mucous membrane; Sexual contact; STI in the United States? c) Candida albicans.
Congenital a) Gonorrhea d) Trichomonas vaginalis.
Nursing: b) Chlamydia A) human papillomavirus (HPV)
-Curettage, Cryotherapy c) Herpes simplex 1 Although a Pap smear does not test directly for
-Avoid sexual contact until lesions are healed d) HPV HPV, dysplasia of cervical cells is strongly
-Strong association with genital dysplasia & B) Chlamydia associated with HPV infection. An abnormal Pap
cervical carcinoma Chlamydia is the most common and fastest- smear is not indicative of chlamydial infection,
-Notify contacts spreading bacterial STI in the United States. trichomoniasis, or candidiasis.

AIDS A nurse is caring for a client diagnosed with a A female college student is distressed at the
AIDS (acquired immunodeficiency syndrome)- a chlamydia infection. The nurse teaches the client recent appearance of genital warts, an
syndrome distinguished by serious deficits in about disease transmission and advises the client assessment finding that her care provider has
cellular immune function associated with positive to inform his sexual partners of the infection. The confirmed as attributable to human papillomavirus
human immunodeficiency virus (HIV) client refuses, stating, "This is my business and (HPV) infection. Which of the following
-Syndrome with CD4/TC counts below 200 I'm not telling anyone. Beside, chlamydia doesn't information should the nurse give the patient?
-Opportunistic infections cause the problems: cause any harm like the other STDs." How should
P.jiroveci pneumonia, C. albicans stomatitis & the nurse proceed? a) "It's important to start treatment soon, so you
cyanosis, meningitis, Cytomegalovirus (significant will be prescribed pills today."
b) "I'd like to give you an HPV vaccination if that's d) Acyclovir Gonorrhea is the second most frequently reported
okay with you." C) Tetracycline communicable disease in the U.S. The incidence
c) "There is a chance that these will clear up on Clients who are allergic to penicillin are given a of syphilis had been increasing for the past 6
their own without any treatment." 14-day regimen of tetracycline or doxycycline. years. One in five people older than age 12 is
d) "Unfortunately, this is going to greatly increase Acyclovir is used to treat genital herpes. infected with the virus that causes genital herpes.
your chance of developing pelvic inflammatory Ceftriaxone may be used for gonorrhea.
disease." Podophyllum resin is used to treat genital warts. A patient has herpes simplex 2 viral infection
C) There is a chance that these will clear up on (HSV-2). The nurse recognizes that which of the
their own without any tx After teaching a group of students about sexually following should be included in teaching the
Genital warts may resolve spontaneously, transmitted infections (STIs), the instructor patient?
although this does not preclude recurrence. determines that additional teaching is necessary
Pharmacologic treatments are topical and when the students identify which STI as curable a) The virus causes "cold sores" of the lips.
vaccination is ineffective after infection has with treatment? b) Treatment is focused on relieving symptoms.
occurred. HPV infection is not correlated with c) The virus may be cured with antibiotics.
pelvic inflammatory disease (PID). a) Syphillis d) The virus when active may not be contracted
b) Gonorrhea during intercourse.
A client is being treated for gonorrhea. Which c) Chlamydia B) Treatment is focused on relieving symptoms
agent would the nurse expect the physician to d) Genital herpes HSV-2 causes genital herpes and is known to
prescribe? D) Genital herpes ascend the peripheral sensory nerves and remain
Besides AIDS, the five most common STIs are inactive after infection, becoming active in times
a) Tetracycline chlamydia, gonorrhea, syphilis, genital herpes, of stress. The virus is not curable, but treatment is
b) Ceftriaxone and genital warts. Of these, chlamydia, aimed at controlling symptoms. HSV-1 causes
c) Penicillin gonorrhea, and syphilis are easily cured with early "cold sores," and varicella zoster causes shingles.
d) Levofloxacin and adequate treatment. Genital herpes recurs.
B) Ceftriaxone A male patient comes to the clinic and is
The microorganism N. gonorrhoeae has become A student nurse is caring for a male patient diagnosed with gonorrhea. Which symptom most
increasingly resistant to penicillin and diagnosed with gonorrhea. The patient is likely prompted him to seek medical attention?
tetracyclines, and fluoroquinolones (such as receiving ceftriaxone and doxycycline. The
levofloxacin). Therefore, the current CDC (2006) nursing instructor asks the student why the a) Painful red papules on the shaft of the penis
recommendation for treating gonorrhea is a single patient is receiving two antibiotics. What is the b) Foul-smelling discharge from the penis
intramuscular dose of a broad-spectrum student nurse's best response? c) Rashes on the palms of the hands and soles of
cephalosporin such as ceftriaxone (Rocephin) or the feet
oral dosing with cefixime (Suprax). a) "This combination of medications will eradicate d) Cauliflower-like warts on the penis
the infection faster than a single antibiotic." B) Foul smelling discharge from the penis
A client with a history of HSV-2 infection asks the b) "Many people infected with gonorrhea are Signs and symptoms of gonorrhea in men include
nurse about future sexual activity. Which of the infected with chlamydia as well." purulent, foul-smelling drainage from the penis
following responses would be most appropriate? c) "The combination of these two antibiotics and painful urination. Rashes on the palms of the
reduces the risk of reinfection." hands and soles of the feet are a sign of the
a) "Inform all potential sexual partners about the d) "There are many resistant strains of gonorrhea, secondary stage of syphilis. Cauliflower-like warts
infection, even if it is inactive.". so more than one antibiotic may be required for on the penis are a sign of human papillomavirus.
b) "Use a condom during sexual activity if the successful treatment." Painful red papules on the shaft of the penis may
infection becomes active again." B) Many people infected with gonorrhea are be a sign of the first stage of genital herpes.
c) "If the infection has healed, you probably don't infected with chlamydia as well
have to use a condom." Treatment of gonorrhea includes the antibiotic Max Thornton, a 24-year-old chef, is being seen
d) "Refrain from all sexual activity until you don't ceftriaxone. Because many people with by a physician at the urology group where you
have another outbreak for a year." gonorrhea have a coexisting chlamydial infection, practice nursing. He has developed a painless
A) Inform all potential sexual partners about the doxycycline or azithromycin is prescribed as well. ulcer on his penis and is rather concerned about
infection, even if its inactive. There has been an increase in the number of his health. The urologist will be communicating
The nurse should advise the client to inform all resistant strains of gonorrhea, but that isn't the his diagnosis of syphilis and prescribing
potential sexual partners of the HSV infection reason for this dual therapy. This combination of treatment. What is the typical span of time
even if it is in an inactive state. The nurse should antibiotics doesn't reduce the risk of reinfection or between infection and developing symptoms with
also advise the client to use a condom during provide a faster cure. syphilis?
sexual activity even if the disease is dormant and
to avoid sexual contact if the infection is active. A client is diagnosed as being in the primary a) 14 days
Condoms do not protect skin and mucous stage of syphilis? Which of the following would b) 21 days
membranes left exposed. the nurse expect as a finding? c) 35 days
d) 28 days
A male client reports urethral pain and a creamy a) Palmar rash B) 21 Days
yellow, bloody discharge from the penis. The b) Development of gummas In syphilis, the time between infection and the first
nurse associates these characteristics with which c) Development of central nervous system lesions occurrence of symptoms is about 21 days
of the following sexually transmitted infections? d) Genital chancres
D) Genital chancres A client is diagnosed with chlamydia and is
a) Gonorrhea Primary syphilis is characterized by the distraught. "How can I have this problem? I don't
b) Candidiasis appearance of a chancre at the site of exposure. have any symptoms!" she says. The nurse
c) Chancroid A rash on the palms is associated with secondary teaches the client that the percentage of women
d) Trichomoniasis syphilis, whereas gummas and central nervous with chlamydia who are asymptomatic is as high
A) Gonorrhea system (CNS) lesions are indicative of tertiary as
In men, the initial symptoms of gonorrhea include syphilis.
urethral pain and a creamy, yellow, sometimes a) 100%
bloody discharge. Candidiasis, trichomoniasis, The nurse is preparing a presentation for a local b) 75%
and bacterial vaginosis are vaginal infections that community group about sexually transmitted c) 50%
can be sexually transmitted, and the male partner infections (STIs). Which of the following would the d) 25%
usually is asymptomatic. Chancroid causes nurse expect to include as the most common STI B) 75%
genital ulcers; the lesions begin as macules, in the United States? As many as 75% of all infected women and 25%
progress to pustules, and then rupture. of all infected men are asymptomatic.
a) Chlamydia
A client with primary syphilis is allergic to b) Syphilis A nurse is teaching a community health class of
penicillin. The nurse would expect the physician c) Genital herpes women and explains that a sexually transmitted
to order which agent? d) Gonorrhea infection (STI) is associated with an increased risk
A) Chlamydia of infertility in women. Which of the following STIs
a) Podophyllum resin Chlamydia is the most common and fastest- would the nurse identify?
b) Tetracycline spreading bacterial STI in the United States, with
c) Ceftriaxone 2.8 million new cases occurring each year. a) Herpes simplex
b) Syphilis c) 18 D) Itching, pain, and the emergence of pustules
c) Chlamydia d) 32 on the penis
d) Gonorrhea A) 26 The initial symptoms of primary genital herpes
C) Chlamydia The CDC (2007) recommends annual screening infection include tingling, itching, and pain in the
Women with chlamydial infection may be for Chlamydia in all sexually active women genital area, followed by eruption of small
asymptomatic and may unknowingly experience younger than 26 years of age and in women with pustules and vesicles. Firm, subcutaneous
damage to the reproductive system. Herpes new or multiple sexual partners. nodules are not associated with herpes simplex
simplex virus (HSV), syphilis, and gonorrhea virus (HSV), and the production of penile
consistently produce symptoms in infected A nurse is assessing a woman with vaginal discharge and cloudy urine are not suggestive of
women. discharge. The nurse suspects bacterial vaginosis the disease.
when the client states which of the following?
An instructor is teaching a group of students A nurse is providing care to a client with
about the incidence of sexually transmitted a) "The discharge is yellowish but thin." chlamydia. The nurse anticipates that the client
infections (STIs) and those that must be reported b) "I noticed a strange fishy odor during my will also receive treatment for which of the
by law. The instructor determines that the period." following?
students have understood the information when c) "The discharge looks almost like cottage
they state that which STI must be reported? cheese." a) Mycoplasma
d) "I've been experiencing some really intense b) Trichomoniasis
a) Syphilis itching." c) Human papillomavirus
b) Condylomata acuminata I noticed a strange fishy odor during my period d) Gonorrhea
c) Genital herpes Bacterial vaginosis is characterized by a fishlike D) Gonorrhea
d) Hepatitis B odor that is particularly noticeable after sexual There is a high incidence of corinfection with
A) Syphilis intercourse or during menstruation. Most clients chlamydia and gonorrhea. Therefore, the client
The law mandates reporting of syphilis, do not experience local discomfort or pain; more would also receive treatment for gonorrhea.
chlamydia, gonorrhea, chancroid, and HIV/AIDs. than one half of clients do not notice any Typically chlamydial infections do not occur in
Genital herpes, hepatitis B, veneral warts symptoms. Intense itching is often associated with conjunction with mycoplasma, trichomoniasis, or
(condylomata acuminata), granuloma inguinale, candidiasis or trichomoniasis. A cottage-cheese human papillomavirus.
and lymphoma venereum are not reportable by like discharge is associated with candidiasis. A
law. thin, yellow discharge is most commonly noted
with trichomoniasis.
The nurse is caring for a patient newly diagnosed
A client with genital herpes asks the nurse about
with HIV. The patient asks what would determine
what to expect with the infection. Which of the A nurse is developing a plan of care for a female
the actual development of AIDS. The nurse's
following responses would be most appropriate? client experiencing her first outbreak of genital
response is based on the knowledge that which of
herpes. Which nursing diagnosis would the nurse
the following is a diagnostic criterion for AIDS?
a) Once you take the medication, the infection will most likely identify as the priority?
A) Presence of HIV antibodies
be gone for good.
B) CD4+ T cell count <200/µl
b) You might have to try several different a) Acute pain related to the development of the
C) White blood cell count <5000/µl
medications before finding one that works. genital lesions
D) Presence of oral hairy leukoplakia
c) Even though you don't have symptoms, you b) Deficient knowledge related to the disease and
B) CD4+ T cell count <200µl
could still spread the infection. its transmission
Diagnostic criteria for AIDS include a CD4+ T-cell
d) You can expect other outbreaks, each of which c) Ineffective coping related to the increased
count <200/µl and/or the development of
will be longer than the first. stress associated with the infection
specified opportunistic infections, cancers,
C) Even though you don't have symptoms, you d) Hyperthermia related to body's response to an
wasting syndrome, or dementia. The other
could still spread the infection infectious process
options may be found in patients with HIV
Genital herpes can be transmitted during A) Acute pain related to the development of the
disease, but do not define the advancement of the
asymptomatic periods of viral shedding. Herpes genital lesions
disease to AIDS.
recurs because after the initial infection, the virus Although deficient knowledge, ineffective coping,
remains dormant in the ganglia of the nerves that and hyperthermia are possible nursing diagnoses,
When teaching a patient infected with HIV
supply the area. Symptoms usually are more the priority would be acute pain because the initial
regarding transmission of the virus to others,
severe with the initial outbreak. Subsequent infection is usually very painful and lasts about 1
which of the following statements made by the
episodes usually are shorter and less intense. week.
patient would identify a need for further
When the virus is active, shedding viral particles
education?
are infectious. Herpes infection is a highly The nurse is gathering data from a male client
A) "I will need to isolate any tissues I use so as
contagious STI that is controllable but not curable. who is suspected of having gonorrhea. Which of
not to infect my family."
Herpes virus responds well to the antiviral drugs the following would the nurse most likely find?
B) "I will notify all of my sexual partners so they
acyclovir, valacyclovir, and famciclovir.
can get tested for HIV."
a) Testicular pain
C) "Unprotected sexual contact is the most
When obtaining the health history from a client, b) Purulent rectal discharge
common mode of transmission."
which factor would lead the nurse to suspect that c) Pain on urination
D) "I do not need to worry about spreading this
the client has an increased risk for sexually d) Skin rash
virus to others by sweating at the gym."
transmitted infections (STIs)? C) Pain on urination
A) I will need to isolate any tissues I use so as not
In men, symptoms usually appear 2 to 6 days
to infect my family.
a) Hive-like rash for the past 2 days after infection. Urethritis with a purulent discharge
HIV is not spread casually. The virus cannot be
b) Clear vaginal discharge and pain on urination are the most common signs
transmitted through hugging, dry kissing, shaking
c) Weight gain of 5 lbs in one year and symptoms. A small proportion of men are
hands, sharing eating utensils, using toilet seats,
d) Five different sexual partners asymptomatic. An anal infection is accompanied
or attending school with an HIV-infected person. It
D) Five different sexual partners by painful bowel elimination and purulent rectal
is not transmitted through tears, saliva, urine,
The number of sexual partners is a risk factor for discharge. Skin rash is associated with
emesis, sputum, feces, or sweat.
the development of STIs. A rash could be related disseminated gonorrhea. Testicular pain would be
to numerous underlying conditions. A weight gain associated with Chlamydia.
A hospital has seen a recent increase in the
of 5 lbs in one year is not a factor increasing
incidence of hospital-acquired infections (HAIs).
one's risk for STIs. A change in the color of A nurse is assisting with a physical examination of
Which of the following measures should be
vaginal discharge such as yellow, milky, or curd- a male client. Which of the following signs and
prioritized in the response to this trend?
like, not clear, would suggest a STI. symptoms is most clearly suggestive of primary
A) Use of gloves during patient contact
genital herpes?
B) Frequent and thorough hand washing
The nurse is giving a presentation about
C) Prophylactic, broad-spectrum antibiotics
chlamydia to a group of adult women. The nurse a) Emergence of hard, painless nodules on the
D) Fitting and appropriate use of N95 masks
would emphasize the need for annual screening shaft of the penis
B) Frequent and thorough hand washing
for this infection in all sexually active women b) Presence of purulent, whitish discharge from
Hand washing remains the mainstay of the
younger than which age? the penis
prevention of HAIs. Gloves, masks, and
c) Production of cloudy, foul-smelling urine
antibiotics may be appropriate in specific
a) 26 d) Itching, pain, and the emergence of pustules
circumstances, but none of these replaces the
b) 35 on the penis
central role of vigilant, thorough hand washing.
 partners) and alcohol (to avoid urethral irritation). functions. Such clients exhibit forgetfulness,
Standard precautions should be used when The disease is not self limiting nor does limited attention span, decreased ability to
providing care for successful treatment confer future resistance. concentrate, and delusional thinking. DSP is
A) All patients regardless of diagnosis. characterized by abnormal sensations, such as
B) Pediatric and gerontologic patients. Screening for chlamydia is recommended for burning and numbness in the feet and later in the
C) Patients who are immunocompromised. young women because hands. Candidiasis is a yeast infection that may
D) Patients with a history of infectious diseases. A) Chlamydia is frequently comorbid with HIV. develop in the oral, pharyngeal, esophageal, or
A) All patients regardless of diagnosis. B) Chlamydial infections may progress to sepsis. vaginal cavities or in the folds of the skin. CMV
Standard precautions are designed for all care of C) Untreated chlamydial infections can lead to infects the choroid and retinal layers of the eye,
all patients in hospitals and health care facilities. infertility. leading to blindness, and can also cause ulcers in
D) Chlamydial infections are treatable only in the the esophagus, colitis, diarrhea, pneumonia, and
The nurse is providing care for a patient who has early stages of infection. encephalitis.
been living with HIV for several years. Which of C) Untreated chlamydial infections can lead to
the following assessment findings most clearly infertility. A client with genital herpes simplex infection asks
indicates an acute exacerbation of the disease? Because of the potential for infertility, screening the nurse, "Will I ever be cured of this infection?"
A) A new onset of polycythemia for chlamydia is recommended for women under Which response by the nurse would be most
B) Presence of mononucleosis-like symptoms 25. Sepsis is not a primary risk of chlamydia and appropriate?
C) A sharp decrease in the patient's CD4+ count is not noted to be strongly correlated with HIV
D) A sudden increase in the patient's WBC count infection. The disease is treatable at all stages of a) "All you need is a dose of penicillin and the
C) A sharp decrease in the patient's CD4+ count infection. infection will be gone."
A decrease in CD4+ count signals an b) "There is a new vaccine available that prevents
exacerbation of the severity of HIV. Polycythemia A 30-year-old female patient has sought care the infection from returning."
is not characteristic of the course of HIV. A because of the recent appearance of itchy lesions c) "Once you have the infection, you develop an
patient's WBC count is very unlikely to suddenly on her vulva, some of which have recently burst. immunity to it."
increase, with decreases being typical. The patient's description of her problem would d) "There is no cure, but drug therapy helps to
Mononucleosis-like symptoms such as malaise, lead you to first suspect reduce symptoms and recurrences."
headache, and fatigue are typical of early HIV A) HIV. D) There is no cure, but drug therapy helps to
infection and seroconversion. B) Gonorrhea. reduce symptoms and recurrences
C) Chlamydia. Genital herpes is a life-long viral infection. No
A patient comes to the clinic after being informed D) Genital herpes. cure exists, but antiviral drug therapy helps to
by a sexual partner of possible recent exposure to D) Gential herpes reduce or suppress symptoms, shedding, and
syphilis. The nurse will examine the patient for A primary episode of genital herpes is often recurrent episodes. A vaccine is available for HPV
which of the following characteristic findings of marked by multiple small, vesicular lesions on the infection but not genital herpes. Penicillin is used
syphilis in the primary clinical stage? genitals. This symptomatology is not commonly to treat syphilis. No immunity develops after a
A) Chancre associated with gonorrhea, chlamydia, or HIV. genital herpes infection.
B) Alopecia
C) Condylomata lata The physical assessment and history of a 29- A client visits the nurse complaining of diarrhea
D) Regional adenopathy year-old female patient are indicative of human every time they eat. The client has AIDS and
A) Chancre papillomavirus (HPV) infection. You would wants to know what they can do to stop having
Chancres appear in the primary stage of the perform patient teaching related to diarrhea. What should the nurse advise?
bacterial invasion of Treponema pallidum, the A) Gardasil.
causative organism of syphilis. The other findings B) Antibiotic therapy. a) Reduce food intake.
do not appear until the secondary stage of C) Wart removal options. b) Encourage large, high-fat meals.
syphilis, occurring a few weeks after the chancres D) Treatment with antiviral drugs. c) Avoid residue, lactose, fat, and caffeine.
appear. C) Wart removal options d) Increase the intake of iron and zinc.
The HPV vaccine (Gardasil) is ineffective in cases C) Avoid residue, lactose, fat, and caffeine
Teaching for patients with a sexually transmitted of existing HPV, whereas neither antiviral nor Diarrhea may subside when the client avoids
disease (STD) would include (select all that apply) antibiotic drugs are effective treatments. Patient residue, lactose, fat, and caffeine. Although eating
A) Treatment of sexual partner is important. teaching should focus on the various options for may seem to cause diarrhea, the client must
B) Douching may help provide relief of itching. physically removing the warts. understand that limiting the intake of food to
C) Cotton undergarments are preferred over control diarrhea only exacerbates wasting. The
synthetic materials. A client is diagnosed as being in the primary client will tolerate a low-fat, high-carbohydrate,
D) Sexual abstinence is indicated during the stage of syphilis? Which of the following would soft or liquid diet better than large, high-fat meals.
communicable phase of the disease. the nurse expect as a finding? The client should be advised to avoid large doses
E) Condoms should be used during as well as of iron and zinc because they can impair the
after treatment during sexual activity. a) Development of gummas functioning of the immune system.
A,C,D,E b) Palmar rash
Douching may spread the infection or alter the c) Genital chancres A client is prescribed didanosine (Videx) as part
local immune responses and is therefore d) Development of central nervous system lesions of his highly active antiretroviral therapy (HAART).
contraindicated in patients with STDs. All other C) Genital chancres Which instruction would the nurse emphasize with
choices are appropriate patient teaching. Primary syphilis is characterized by the this client?
appearance of a chancre at the site of exposure.
A 22-year-old male is being treated at a college A rash on the palms is associated with secondary a) "You should take the drug with an antacid."
health care clinic for gonorrhea. Which of the syphilis, whereas gummas and central nervous b) "It doesn't matter if you take this drug with or
following teaching points should the nurse include system (CNS) lesions are indicative of tertiary without food."
in patient teaching? syphilis. c) "Be sure to take this drug about 1/2 hour before
A) "While being treated for the infection, you will or 2 hours after you eat."
not be able to pass this infection on to your A client with AIDS is brought to the clinic by their d) "When you take this drug, eat a high-fat meal
sexual partner." family. The family tells the nurse the client has immediately afterwards."
B) "While you're taking your antibiotics, you will become forgetful, with a limited attention span, C) Be sure to take this drug about 1/2 hour before
need to abstain from participating in sexual decreased ability to concentrate, and delusional or 2 hours after you eat
activity or drinking alcohol." thinking. What condition is represented by these Didanosine should be taken 30 to 60 minutes
C) "It's important to complete your full course of symptoms? before or 2 hours after meals. Other antiretroviral
antibiotics in order to ensure that you become agents, such as abacavir, emtricitabine, or
resistant to reinfection." a) Cytomegalovirus (CMV) lamivudine can be taken without regard to meals.
D) "The symptoms of gonorrhea will resolve on b) Distal sensory polyneuropathy (DSP) High-fat meals should be avoided when taking
their own, but it is important for you to abstain c) HIV encephalopathy amprenavir. Atazanavir should be taken with food
from sexual activity while this is occurring." d) Candidiasis and not with antacids.
B) While you're taking your antibiotics, you will C) HIV encephalopathy
need to abstain from participating in sexual HIV encephalopathy, also called AIDS dementia When developing the plan of care for a client with
activity or drinking alcohol complex or ADC, is a neurologic condition that a primary immunodeficiency, which nursing
Treatment for gonorrhea necessitates abstinence causes the degeneration of the brain, especially diagnosis would be the priority?
from sexual activity (to prevent infection of in areas that affect mood, cognition, and motor
a) Risk for infection related to altered immune cell b) Chlamydia he's always sick." During the history and physical
function c) Syphilis examination, which of the following would alert
b) Impaired skin integrity related to persistent d) Gonorrhea the nurse to suspect a primary
deep skin abscesses D) Gonorrhea immunodeficiency?
c) Anxiety related to an inherited disorder The signs and symptoms of gonorrhea include
d) Grieving related to the poor prognosis of the fever; urethral, vaginal, and rectal discharge; and a) Superficial wound on the child's left leg
condition in untreated cases, arthritis. b) History of fungal diaper rash
A) Risk for infections related to altered immune c) Ten ear infections in the past year
cell function A female client with an anal gonorrheal infection d) Weight within age-appropriate parameters
Although anxiety and impaired skin integrity may experiences painful bowel elimination and a C) Ten ear infections in the past year
be appropriate, the priority nursing diagnosis for purulent rectal discharge. The nurse would expect The mother has already reported one of the
any immunodeficiency is the risk for infection. to find which of the following once the warning signs associated with primary
Although primary immunodeficiencies can be microorganism disseminates throughout the immunodeficiencies--the use of antibiotics for 2 or
serious, they are rarely fatal. Therefore, the body? more months with little effect. Another warning
nursing diagnosis of grieving would be sign is eight or more new ear infections within 1
inappropriate. a) Painful joints year. Therefore, the report of 10 ear infections in
b) Intermenstrual bleeding the past year would increase the nurse's
A group of students are reviewing class material c) Sore throat suspicion. Recurrent, deep skin, or organ
on sexually transmitted infections in preparation d) Painful urination abscesses, failure of an infant to gain weight or
for a test. The students demonstrate A) Painful joints grow normally, and persistent thrush (yeast
understanding of the material when they identify The client with an anal gonorrheal infection infection) in the mouth or elsewhere on the skin
which of the following as the cause of experiences symptoms of gonorrhea where the after age 1 year would be additional warning
condylomata? microorganism has invaded the rectum. After the signs. A superficial wound on the leg, age-
microorganism disseminates throughout the body, appropriate weight, and a history of a fungal
a) Human papilloma virus the client may manifest a skin rash, fever, and diaper rash would not be considered warning
b) Haemophilus ducreyi bacillus painful joints. Other symptoms such as infections signs.
c) Herpes virus of the urinary tract or vagina, sore throat,
d) Treponema pallidum intermenstrual bleeding due to cervicitis, and A nurse educator is preparing to discuss
A) Human papilloma virus painful urination are associated with the immunodeficiency disorders with a group of fellow
Genital warts or condylomata are caused by the organism's invasion of those structures, nurses. What would the nurse identify as the most
human papilloma virus (HPV). Herpes virus depending on the nature of the sexual contact. common secondary immunodeficiency disorder?
causes genital herpes. Treponema pallidum is the
cause of syphilis. Haemophilus ducreyi bacillus is Which information would be most appropriate for
the cause of chancroid. a nurse to provide to a client who has never used a) SCID
a condom? b) AIDS
After teaching a client with immunodeficiency c) DAF
about ways to prevent infection, the nurse a) A condom can be used, even if it is old, so long d) CVID
determines that teaching was successful when as the pack is unopened. B) AIDS
the client states which of the following? b) A new condom should be used for each sex AIDS, the most common secondary disorder, is
act. perhaps the best-known secondary
a) "I will clean my kitchen counter with hot water." c) Cheap condoms of any brand can be used immunodeficiency disorder. It results from
b) "Alcohol is good to clean any skin areas that based on monetary constraints. infection with the human immunodeficiency virus
are dry or chafed." d) A fresh condom should be unrolled over a limp (HIV). DAF refers to lysis of erythrocytes due to
c) "I should avoid eating cooked fruits and penis before it becomes erect. lack of decay-accelerating factor (DAF) on
vegetables." B) A new condom should be used for each sex erythrocytes. CVID is a disorder that
d) "I should avoid being around other people who act encompasses various defects ranging from IgA
have an infection." Information that is important to provide when deficiency (in which only the plasma cells that
D) I should avoid being around other people who explaining the use of a condom include the produce IgA are absent) to severe
have an infection. following: use condoms manufactured and tested panhypoglobulinemia (in which there is a general
Strategies to prevent infection include avoiding in the United States, discard old or deteriorated lack of immunoglobulins in the blood). Severe
being around others who have an infection and condoms, unroll a fresh condom over the erect combined immunodeficiency disease (SCID) is a
avoiding crowds. The client should avoid penis, remove the condom before the penis disorder in which both B and T cells are missing.
consumption of raw fruits and vegetables and use becomes limp, and use a new condom for each
creams and emollients to prevent or manage dry, sex act. A student nurse is doing clinical hours at an
chafed, or cracked skin. A disinfectant, not just OB/GYN clinic. The student is helping to develop
hot water, should be used to clean kitchen and A client has undergone diagnostic testing for a plan of care for a patient with gonorrhea has
bathroom surfaces. human immunodeficiency virus (HIV) using the presented at the clinic. The student knows that
enzyme immunoassay (EIA) test. The results are the care plan for this patient should be include
A 45-year-old waitress with a history of IV drug positive and the nurse prepares the client for what in the treatment of gonorrhea?
use also is HIV-positive. She has been following additional testing to confirm seropositivity. The
her antiretroviral medication regimen faithfully and nurse would prepare the client for which test? a) Concurrent treatment for chlamydia
is doing well. She's attending college to get a b) Avoidance of the use of tampons
social work degree and is focused on a bright a) Nucleic acid sequence-based amplification c) Vaginal smears every 6 months
future. In her regular CD counts, what factor will b) Western blot assay d) Radiation therapy to destroy cancerous cells
indicate she has progressed from HIV to AIDS? c) OraSure test A) Concurrent treatment for chlamydia
d) p24 antigen capture assay Because of the high incidence of coinfection with
a) CD count > 200/mm B) Western blot assay chlamydia and gonorrhea, treatment for
b) CD count > 100/mm A positive EIA test indicates seropositivity. To gonorrhea should also include treatment for
c) CD count < 200/mm confirm this, a Western blot assay would be done. chlamydia. One cause of cervicitis is chlamydia. A
d) CD count < 100/mm The OraSure test uses saliva to perform an EIA management strategy used in the treatment of
C) CD count <200/mm test. The p24 antigen test and nucleic acid chlamydia is a cytologic examination of cervical
A CD (T-cell) count of less than 500/mm indicates sequence-based amplification test are used to smear. Avoiding the use of tampons is part of the
immune suppression; a CD (T-cell) count of test viral load and evaluate response to treatment. self-care management of a patient with possible
200/mm or less is an indicator of AIDS. However, the reverse transcriptase-polymerase toxic shock syndrome (TSS). Gonorhhea is
chain reaction (RT-PCR) and nucleic acid considered a sexually transmitted infection (STI),
A patient comes to the free clinic complaining of sequence-based tests have replaced the p24 not a carcinoma.
urethral discharge. On assessment, the nurse antigen test. The RT-PCR tests may be used to
notes that the patient is feverish. During the confirm a positive EIA result. You are caring for a client who has a diagnosis of
assessment, the patient admits to having HIV. Part of this client's teaching plan is educating
unprotected sex. The nurse suspects the patient A mother brings her young child to the clinic for the client about his or her medications. What is
may have a diagnosis of what? an evaluation of an infection. The mother states, essential for the nurse to include in the teaching
"He's been taking antibiotics now for more than 2 of this client regarding medications?
a) HIV months and still doesn't seem any better. It's like
a) The use of condoms 4. An arteriovenous shunt is a less common form
b) What vaccinations to have The client with chronic renal failure is scheduled of access site but carries a risk for bleeding when
c) Side effects of drug therapy for hemodialysis this morning is due to receive a it is used because two ends of an external
d) The action of each antiretroviral drug daily dose of enalapril (Vasotec). The nurse cannula are tunneled subcutaneously into an
C) Side effects of drug therapy should plan to administer this medication: artery and a vein, and the ends of the cannula are
Describing the side effects of drug therapy is 1. During dialysis. joined. If accidental disconnection occurs, the
essential, with the admonition to refrain from 2. Just before dialysis. client could lose blood rapidly. For this reason,
discontinuing any of the prescribed drugs without 3. The day after dialysis. small clamps are attached to the dressing that
first consulting the prescribing physician. Although 4. On return from dialysis. covers the insertion site for use if needed. The
the client may want to know how the drugs work 4. Antihypertensive medications such as enalapril shunt site also should be assessed at least every
in general, the specific action of each are given to the client following hemodialysis. This 4 hours.
antiretroviral drug is not essential information. prevents the client from becoming hypotensive
Teaching about condoms and vaccinations may during dialysis and also from having the The nurse develops a postprocedure plan of care
be appropriate, but these topics are not directly medication removed from the bloodstream by for a client who had a renal biopsy. The nurse
related to the client's HIV medications. dialysis. No rationale exists for waiting an entire avoids documenting which intervention in the
day to resume the medication. This would lead to plan?
A client has been admitted to the hospital for ineffective control of the blood pressure. 1. Administering analgesics as needed.
urinary tract infection an dehydration. The nurse 2. Encouraging fluids to at least 3 L in the first 24
determines that the client has received adequate The client with chronic renal failure has an hours.
volume replacement if the BUN drops to: indwelling abdominal catheter for peritoneal 3. Testing serial urine samples with dipsticks for
1. 3 mg/dL dialysis. The client spills water on the catheter occult blood.
2. 15 mg/dL dressing while bathing. The nurse should 4. Ambulating the client in the room and hall for
3. 29 mg/dL immediately: short distances.
4. 35 mg/dL 1. Change the dressing. 4. Following renal biopsy, the nurse ensures that
2. The normal blood urea nitrogen level is 8 to 25 2. Reinforce the dressing. the client remains in bed for at least 24 hours.
mg/dL. Values such as those in options 3 and 4 3. Flush the peritoneal dialysis catheter. Vital signs and puncture site assessments are
reflect continued dehydration. Option 1 reflects a 4. Scrub the catheter with providone-iodine. done frequently during this time. Encouraging
lower than normal value, which may occur with 1. Clients with peritoneal dialysis catheters are at fluids is done to reduce possible clot formation at
fluid volume overload, among other conditions. high risk for infection. A wet dressing is a conduit the biopsy site. Serial urine samples are assayed
for bacteria to reach the catheter insertion site. by Hematest with urine dipsticks to evaluate
An adult client has had lab work done as part of a The nurse ensures that the dressing is kept dry at bleeding. Analgesics often are needed to manage
routine physical exam. The nurse interprets that all times. Reinforcing the dressing is not a safe the renal colic pain that some clients feel after this
the client may have a mild degree of renal practice to prevent infection in this circumstance. procedure.
insufficiency if which of the following serum Flushing the catheter is not indicated. Scrubbing
creatinine levels is noted? the catheter with povidone-iodine is done at the The client with urolithiasis has a history of chronic
1. 0.2 mg/dL time of connection or disconnection of peritoneal urinary tract infections. The nurse plans teaching
2. 0.5 mg/dL dialysis. the client to avoid which of the following?
3. 1.9 mg/dL 1. Long-term use of antibiotics.
4. 3.5 mg/dL The client being hemodialyzed suddenly becomes 2. Wearing synthetic underwear and pantyhose.
3. The normal serum creatinine level for adults is short of breath and complains of chest pain. The 3. High--phosphate foods, such as dairy products.
0.6 to 1.3 mg/dL. The client with a mild degree of client is tachycardic, pale, and anxious. The nurse 4. Foods that make the urine more acidic, such as
renal insufficiency would have a slightly elevated suspects air embolism. The priority action for the cranberries.
level. A creatinine level of 0.2 mg/dL is low, and a nurse is to: 2. Urolithiasis (struvite stones) can result from
level of 0.5 mg/dL is just below normal. A 1. Discontinue dialysis and notify the physician. chronic infections. They form in urine that is
creatinine level of 3.5 mg/dL may be associated 2. Monitor vital signs every 15 minutes for the alkaline and rich in ammonia, such as with a
with acute or chronic renal failure. next hour. urinary tract infection. Teaching should focus on
3. Continue dialysis at a slower rate after prevention of infections and ingesting foods to
The nurse instructs a client with renal failure who checking the lines for air. make the urine more acidic. The client should
is receiving hemodialysis about dietary 4. Bolus the client with 500 mL of normal saline to wear cotton (not synthetic) underclothing to
modifications. The nurse determines that the break up the embolus. prevent the accumulation of moisture and to
client understands these dietary modifications if 1. If the client experiences air embolus during prevent irritation of the perineal area, which can
the client selects which items from the menu? hemodialysis, the nurse should terminate dialysis lead to infection.
1. Cream of wheat, blueberries, coffee immediately, notify the physician, and administer
2. Sausage and eggs, banana, orange juice. oxygen as needed. Options 2, 3, and 4 are The client who has a history of gout also is
3. Bacon, cantaloupe melon, tomato juice. incorrect. diagnosed with urolithiasis and the stones are
4. Cured pork, grits, strawberries, orange juice. determined to be of uric acid type. The nurse
1. The diet for a client with renal failure who is The nurse has completed client teaching with the gives the client instructions in which foods to limit,
receiving hemodialysis should include controlled hemodialysis client about self-monitoring between including:
amounts of sodium, phosphorus, calcium, hemodialysis treatments. The nurse determines 1. Milk
potassium, and fluids. Options 2, 3, and 4 are that the client best understands the information if 2. Liver
high in sodium, phosphorus and potassium. the client states to record daily the: 3. Apples
1. Amount of activity. 4. Carrots
The client with acute renal failure has a serum 2. Pulse and respiratory rate. 2. The client with uric acid stones should avoid
potassium level of 6.0 mEq/L. The nurse would 3. Intake and output and weight. foods containing high amounts of purines. This
plan which of the following as a priority action? 4. Blood urea nitrogen and creatinine levels. includes limiting or avoiding organ meats such as
1. Check the sodium level. 3. The client on hemodialysis should monitor fluid liver, brain, heart, kidney, and sweetbreads. Other
2. Place the client on a cardiac monitor. status between hemodialysis treatments by foods to avoid include herring, sardines,
3. Encourage increased vegetables in the diet. recording intake and output and measuring weight anchovies, meat extracts, consommés, and
4. Allow an extra 500 mL of fluid intake to dilute daily. Ideally, the hemodialysis client should not gravies. Foods that are low in purines include all
the electrolyte concentration. gain more than 0.5 kg of weight/day. fruits, many vegetables, milk, cheese, eggs,
2. The client with hyperkalemia is at risk of refined cereals, sugars and sweets, coffee, tea,
developing cardiac dysrhythmias and cardiac The client with an external arteriovenous shunt in chocolate, and carbonated beverages.
arrest. Because of this, the client should be place for hemodialysis is at risk for bleeding. The
placed on a cardiac monitor. Fluid intake is not priority nurse action would be to: The client arrives at the emergency department
increased because it contributes to fluid overload 1. Check the shunt for the presence of bruit and with complaints of low abdominal pain and
and would not affect the serum potassium level thrill. hematuria. The client is afebrile. The nurse next
significantly. Vegetables are a natural source of 2. Observe the site once as time permits during assesses the client to determine a history of:
potassium in the diet, and their use would not be the shift. 1. Pyelonephritits
increased. The nurse also may assess the 3. Check the results of the prothrombin times as 2. Glomerulonephritis
sodium level because sodium is another they are determined. 3. Trauma to the bladder or abdomen
electrolyte commonly measured with the 4. Ensure that small clamps are attached to the 4. Renal cancer in the client's family
potassium level. However, this is not a priority arteriovenous shunt dressing. 3. Bladder trauma or injury should be considered
action of the nurse. or suspected in the client with low abdominal pain
and hematuria. Glomerulonephritis and per protocol but are not necessarily done after the 3. Continue to monitor vital signs.
pyelonephritis would be accompanied by fever hemodialysis treatment has ended. 4. Monitor the site of the shunt for infection.
and are thus not applicable to the client in this 3. The client may have an elevated temperature
question. Renal cancer would not cause pain that The hemodialysis client with a left arm fistula is at following dialysis because the dialysis machine
is felt in the low abdomen; rather pain would be in risk for arterial steal syndrome. The nurse warms the blood slightly. If the temperature is
the flank area. assesses this client for which of the following elevated excessively and remains elevated,
manifestations? sepsis would be suspected and a blood sample
The client is admitted to the emergency 1. Warmth, redness, and pain in the left hand. would be obtained as prescribed for culture and
department following a motor vehicle accident. 2. Pallor, diminished pulse, and pain in the left sensitivity determinations.
The client was wearing a lap seat belt when the hand.
accident occurred and now the client has 3. Edema and reddish discoloration of the left The nurse is performing an assessment on a
hematuria and lower abdominal pain. To assess arm. client who has returned from the dialysis unit
further whether the pain is caused by bladder 4. Aching pain, pallor, and edema of the left arm. following hemodialysis. The client is complaining
trauma, the nurse asks the client if the pain is 2. Steal syndrome results from vascular of headache and nausea and is extremely
referred to which of the following area? insufficiency after creation of a fistula. The client restless. Which of the following is the most
1. Hip exhibits pallor and a diminished pulse distal to the appropriate nursing action?
2. Shoulder fistula. The client also complains of pain distal to 1. Monitor the client.
3. Umbilicus the fistula, caused by tissue ischemia. Warmth, 2. Notify the physician.
4. Costovertebral angle redness, and pain probably would characterize a 3. Elevate the head of the bed.
2. Bladder trauma or injury is characterized by problem with infection. The manifestations 4. Medicate the client for nausea.
lower abdominal pain that may radiate to one of described in options 3 and 4 are incorrect. 2. Disequilibrium syndrome may be caused by the
the shoulders. Bladder injury pain does not rapid decreases in the blood urea nitrogen level
radiate to the umbilicus, costovertebral angle, or The nurse is reviewing the client's record and during hemodialysis. These changes can cause
hip. notes that the physician has documented that the cerebral edema that leads to increased
client has a renal disorder. On review of the lab intracranial pressure. The client is exhibiting early
A nurse is assessing the patency of a client's left results, the nurse most likely would expect to note signs of disequilibrium syndrome and appropriate
arm arteriovenous fistula prior to initiating which of the following? treatments with anticonvulsive medications and
hemodialysis. Which finding indicates that the 1. Decreased hemoglobin level. barbiturates may be necessary to prevent a life-
fistula is patent? 2. Elevated BUN threatening situation. The physician must be
1. Palpation of a thrill over the fistula. 3. Decreased red blood cell count. notified.
2. Presence of a radial pulse in the left wrist. 4. Decreased white blood cell count.
3. Absence of a bruit on auscultation of the fistula. 2. Measuring the blood urea nitrogen level is a The nurse is reviewing the list of components
4. Capillary refill less than 3 seconds in the nail frequently used laboratory test to determine renal contained in the peritoneal dialysis solution with
beds of the fingers of the left hand. function. The blood urea nitrogen level starts to the client. The client asks the nurse about the
1. The nurse assesses the patency of the fistula rise when the glomerular filtration rate falls below purpose of the glucose contained in the solution.
by palpating for the presence of a thrill or 40% to 60%. A decreased hemoglobin level and The nurse bases the response on knowing that
auscultating for a bruit. The presence of a thrill red blood cell count may be noted if bleeding from the glucose:
and bruit indicate patency of the fistula. Although the urinary tract occurs or if erythropoietic function 1. Decreases the risk of peritonitis.
the presence of a radial pulse in the left wrist and by the kidney is impaired. An increased white 2. Prevents disequilibrium syndrome.
capillary refill shorter than 3 seconds in the nail blood cell count is most likely to be noted in renal 3. Increases osmotic pressure to produce
beds of the fingers on the left hand are normal disease. ultrafiltration.
findings, they do not assess fistula patency. 4. Prevents excess glucose from being removed
Following a renal biopsy, the client complains of from the client.
The client newly diagnosed with chronic renal pain at the biopsy site that radiates to the front of 3. Increasing the glucose concentration makes
failure recently has begun hemodialysis. Knowing the abdomen. The nurse interprets this complaint the solution more hypertonic. The more
that the client is at risk for disequilibrium and further assesses the client for: hypertonic the solution, the higher the osmotic
syndrome, the nurse assesses the client during 1. Bleeding. pressure for ultrafiltration and thus the greater the
dialysis for: 2. Infection. amount of fluid removed from the client during an
1. Hypertension, tachycardia, and fever. 3. Renal colic. exchange. Options 1, 2, and 4 do not identify the
2. Hypotension, bradycardia, and hypothermia. 4. Bladder perforation. purpose of the glucose.
3. Restlessness, irritability, and generalized 1. If pain originates at the biopsy site and begins
weakness. to radiate to the flank area and around the front of The nurse is preparing to care for a client
4. Headache, deteriorating level of the abdomen, bleeding should be suspected. receiving peritoneal dialysis. Which of the
consciousness, and twitching. Hypotension, a decreasing hematocrit level, and following would be included in the nursing plan of
4. Disequilibrium syndrome is characterized by gross or microscopic hematuria also would care to prevent the major complication associated
headache, mental confusion, decreasing level of indicate bleeding. Signs of infection would not with peritoneal dialysis?
consciousness, nausea, vomiting, twitching, and appear immediately following a biopsy. The 1. Maintain strict aseptic technique.
possible seizure activity. Disequilibrium syndrome biopsy site would be the flank area and not the 2. Add heparin to the dialysate solution.
is caused by rapid removal of solutes from the lower abdomen. No data are given to support the 3. Change the catheter site dressing daily.
body during hemodialysis. At the same time, the presence of renal colic. 4. Monitor the client's level of consciousness.
blood-brain barrier interferes with the efficient 1. The major complication of peritoneal dialysis is
removal of wastes from brain tissue. As a result, A client is admitted to the hospital with a peritonitis. Strict aseptic technique is required in
water goes into cerebral cells because of the diagnosis of early-stage chronic renal failure. caring for the client receiving this treatment.
osmotic gradient, causing brain swelling and Which of the following should the nurse expect to Although option 3 may assist in preventing
onset of symptoms. The syndrome most often note on client assessment? infection, this option relates to an external site.
occurs in clients who are new to dialysis and is 1. Anuria. Options 2 and 4 are unrelated to the major
prevented by dialyzing for shorter times or at 2. Polyuria. complication of peritoneal dialysis.
reduced blood flow rates. 3. Oliguria.
4. Polydypsia. A client newly diagnosed with renal failure has
A client with chronic renal failure has completed a 2. Polyuria occurs early in chronic renal failure just been started on peritoneal dialysis. During the
hemodialysis treatment. The nurse would use and, if untreated, can cause severe dehydration. infusion of the dialysate, the client complains of
which of the following standard indicators to Polyuria progresses to anuria, and the client loses abdominal pain. Which action by the nurse is
evaluate the client's status after dialysis? all normal kidney functions. Oliguria and anuria appropriate?
1. Vital signs and weight. are not early signs, and polydipsia is unrelated to 1. Stop the dialysis.
2. Potassium level and weight. chronic renal failure. 2. Slow the infusion.
3. Vital signs and BUN. 3. Decrease the amount to be infused.
4. BUN and creatinine levels. The client with chronic renal failure returns to the 4. Explain that the pain will subside after the first
1. Following dialysis, the client's vital signs are nursing unit following a hemodialysis treatment. few exchanges.
monitored to determine whether the client is On assessment, the nurse notes that the client's 4. Pain during the inflow of dialysate is common
remaining hemodynamically stable. Weight is temperature is 100.2F. Which of the following is during the first few exchanges because of
measured and compared with the client's the appropriate nursing action? peritoneal irritation; however, the pain usually
predialysis weight to determine effectiveness of 1. Encourage fluids. disappears after 1 to 2 weeks of treatment. The
fluid extraction. Laboratory studies are done as 2. Notify the physician.
infusion amount should not be decreased, and 2. Check the level of the drainage bag. 3. Short attention span.
the infusion should not be slowed or stopped. 3. Reposition the client to his or her side. 4. Presence of family.
4. Place the client in good body alignment. 4. The client with CRF may have several barriers
The nurse is instructing a client with diabetes 5. Check the peritoneal dialysis system for kinks. to learning. Anxiety about the disease and its
mellitus about peritoneal dialysis. The nurse tells 6. Increase the flow rate of the peritoneal dialysis ramifications frequently may interfere with
the client that it is important to maintain the solution. learning. Physiological effects of the disease
prescribed dwell time for the dialysis because of 2, 3, 4, 5. If outflow drainage is inadequate, the process also impair the client's mental
the risk of: nurse attempts to stimulate outflow by changing functioning. Specifically, the client may exhibit a
1. Infection. the client's position. Turning the client to the other short attention span and have memory deficits.
2. Hyperglycemia. side or making sure that the client is in good body Mental functioning usually improves once
3. Hypophosphatemia. alignment may assist with outflow drainage. The hemodialysis has begun. The presence of family
4. Disequilibrium syndrome. drainage bag needs to be lower than the client's members is helpful because they need to
2. An extended dwell time increases the risk of abdomen to enhance gravity drainage. The understand the disease and treatment and may
hyperglycemia in the client with diabetes mellitus connecting tubing and peritoneal dialysis system help reinforce information with the client after the
as a result of absorption of glucose from the are also checked for kinks or twisting and the formal teaching session is over.
dialysate and electrolyte changes. Diabetic clients clamps on the system are checked to ensure that
may require extra insulin when receiving they are open. There is no reason to contact the A nurse is analyzing the posthemodialysis lab test
peritoneal dialysis. physician. Increasing the flow rate is an results for a client with chronic renal failure (CRF).
inappropriate action and is not associated with the The nurse interprets that the dialysis is having an
A client diagnosed with polycystic kidney disease amount of outflow solution. expected but nontherapeutic effect if the results
has been taught about the treatment plan for this indicate a decreased:
disease. The nurse determines that the client The client who has suffered a crush injury to the 1. Phosphorus.
needs additional teaching if the client states that leg has a highly positive urine myoglobin level. 2. Creatinine.
the treatment plan includes: The nurse assesses this particular client carefully 3. Potassium.
1. Genetic counseling. for signs of: 4. Red blood cell count
2. Sodium restriction. 1. Brain attack (stroke) 4. Hemodialysis typically lowers the amounts of
3. Increased water intake. 2. Acute tubular necrosis fluid, sodium, potassium, urea nitrogen,
4. Antihypertensive medications. 3. Respiratory failure creatinine, uric acid, magnesium, and phosphate
2. Individuals with polycystic kidney disease seem 4. Myocardial infarction levels in the blood. Hemodialysis also worsens
to waste rather than retain sodium. Thus, they 2. The normal urine myoglobin level is negative. anemia, because RBCs are lost in dialysis from
need increased sodium and water intake. After extensive muscle destruction or damage, blood sampling and anticoagulation during the
Aggressive control of hypertension is essential. myoglobin is released into the bloodstream, procedure, and from residual blood that is left in
Genetic counseling is advisable because of the where it is cleared from the body by the kidneys. the dialyzer. Although all of these results are
hereditary nature of the disease. When there is a large amount of myoglobin being expected, only the lowered RBC count is
cleared from the body, there is a risk of the renal nontherapeutic and worsens the anemia already
The nurse is caring for the client who has tubules being clogged with myoglobin, causing caused by the disease process.
undergone renal angiography using the left acute tubular necrosis. This is one form of acute
femoral artery for access. The nurse determines renal failure. A client diagnosed with chronic renal failure
that the client is experiencing a complication of (CRF) is scheduled to begin hemodialysis. The
the procedure if which of the following is Epoetin alfa (Epogen) is prescribed for a client nurse assesses that which of the following
observed? diagnosed with chronic renal failure. The client neurological and psychosocial manifestations if
1. Urine output, 50 mL/hr asks the nurse about the purpose of the exhibited by this client would be unrelated to the
2. Blood pressure, 110/74 mm Hg medication. The appropriate response would be CRF?
3. Pallor and coolness of the left leg. which of the following? 1. Labile emotions.
4. Absence of hematoma in the left groin. 1. It is used to lower your blood pressure. 2. Withdrawal.
3. Potential complications after renal angiography 2. It is used to treat anemia. 3. Euphoria.
include allergic reaction to the dye, renal damage 3. It will help to increase the potassium level in 4. Depression.
from the dye, and vascular complications, which your body. 3. The client with CRF often experiences a variety
include hemorrhage, thrombosis, or embolism. 4. It is an anticonvulsant medication given to all of psychosocial changes. These are related to
The nurse detects these complications by noting clients after dialysis to prevent seizure activity. uremia, as well as the stress associated with
signs and symptoms of allergic reaction, 2. Epoetin alfa is a medication that is used to treat living with a chronic disease that is life-
decreased urine output, hematoma or anemia. Options 1, 3, and 4 are incorrect. threatening. Clients with CRF may have labile
hemorrhage at the insertion site, and/or signs of Hypertension is a side effect. Hyperkalemia and emotions or personality changes and may exhibit
decreased circulation to the affected leg. seizures are adverse effects of the medication. withdrawal, depression, or agitation. Delusions
and psychosis also can occur. Euphoria is not
The nurse has taught the client with polycistic A client has developed acute renal failure (ARF) part of the clinical picture for the client in renal
kidney disease about management of the disorder as a complication of glomerulonephritis. The failure.
and prevention and recognition of complications. nurse assesses the client for which of the
The nurse determines that the client understands following as an expected manifestation of ARF? A client with chronic renal failure (CRF) is on fluid
the instructions if the client states that there is no 1. Hypertension restriction. The client is fatigued and therefore has
reason to be concerned about: 2. Bradycardia. a limited tolerance for activity. The client takes
1. Burning on urination. 3. Decreased cardiac output aluminum hydroxide gel (Alternagel) as a
2. A temperature of 100.6F 4. Decreased central venous pressure phosphate binder. On the basis of this
3. New-onset shortness of breath. 1. ARF caused by glomerulonephritis is classified information, the nurse determines that the client is
4. A blood pressure of 105/68 mmHg as intrinsic or intrarenal failure. This form of ARF most at risk for which of the following nursing
4. The client with polycystic kidney disease is commonly manifested by hypertension, diagnoses?
should report any signs and symptoms of urinary tachycardia, oliguria, lethargy, edema, and other 1. Impaired physical mobility.
tract infection so that treatment may begin signs of fluid overload. ARF from prerenal causes 2. activity intolerance.
promptly. Lowered blood pressure is not a is characterized by decreased blood pressure, or 3. Deficient fluid volume.
complication of polycystic kidney disease, and it is a recent history of the same, tachycardia, and 4. Constipation.
an expected effect of antihypertensive therapy. decreased cardiac output and central venous 4. The client with renal failure is almost certain to
The client would be concerned about increases in pressure. Bradycardia is not part of the clinical have a problem with constipation as a result of
blood pressure because control of hypertension is picture for any form of renal failure. factors such as fluid restriction, fatigue that limits
essential. The client may experience heart failure exercise, and dietary restrictions. In addition,
as a result of hypertension, and thus any A client newly diagnosed with chronic renal failure phosphate-binding antacids such as aluminum
symptoms of heart failure, such as shortness of (CRF) has many learning needs regarding the hydroxide gel cause constipation as a side effect.
breath, are also a concern. disease. The nurse prepares a teaching plan to
help the client adapt to the disease. The nurse A nurse is working with the client newly
The nurse monitoring a client receiving peritoneal recognizes that which of the following client diagnosed with chronic renal failure (CRF) to set
dialysis notes that the clietn's outflow is less than characteristics or factors is least likely to interfere up a schedule for hemodialysis. The client states,
the inflow. Select all nursing actions in the with the client's ability to learn? "This is impossible! How can I even think about
situation that apply. 1. Anxiety. leading a normal life again if this is what I'm going
1. Contact the physician. 2. Memory deficits.
to have to do?" The nurse assesses that the client body. It can be prevented by avoiding or limiting 4. Dialysis cleanses the blood from accumulated
is exhibiting: the use of phosphate-binding agents that contain waste products.
1. Withdrawal aluminum. 1. Dialysate is made from clear water and
2. Depression chemicals and is free from any metabolic waste
3. Anger A client undergoing hemodialysis is at risk for products or medications. Bacteria and other
4. Projection bleeding from the heparin used during the microorganisms are too large to pass through the
3. Psychosocial reactions to CRF and hemodialysis treatment. The nurse assesses for membrane; therefore, the dialysate does not need
hemodialysis are varied and may include anger. this occurrence by periodically checking the to be sterile. The dialysate is warmed to
Other reactions include personality changes, results of which of the following lab tests? approximately 100° F to increase the efficiency of
emotional lability, withdrawal, and depression. 1. Partial thromboplastin time (PTT) diffusion and to prevent a decrease in the client's
The individual client's response may vary 2. Prothrombin time (PT) blood temperature. Heparin sodium inhibits the
depending on the client's personality and support 3. Thrombin time (TT) tendency of blood to clot when it comes in contact
systems. The client in this question is exhibiting 4. Bleeding time with foreign substances. Option 4 is the purpose
anger. The client has not projected blame on the 1. Heparin is the anticoagulant used most often of dialysis.
nurse, nor does the client statement reflect during hemodialysis. The hemodialysis nurse
withdrawal or depression. monitors the extent of anticoagulation by checking A nurse is caring for a client with acute renal
the PTT, which is the appropriate measure of failure (ARF). When performing an assessment,
A client undergoing hemodialysis has an heparin effect. The PT is used to monitor the the nurse would expect to note which of the
arteriovenous (AV) fistula in the left arm. A related effect of warfarin (Coumadin) therapy. Thrombin following breathing patterns?
nursing diagnosis for the client is risk for infection. and bleeding times are not used to measure the 1. Decreased respirations.
The nurse should formulate which of the following effect of heparin therapy, although they are useful 2. Apneic
outcome goals as most appropriate for this in the diagnosis of other clotting abnormalities. 3. Cheyne-Stokes
nursing diagnosis? 4. Kussmaul's
1. The client's temperature remains less than A client is undergoing diagnostic tests to rule out 4. Clinical manifestations associated with ARF
101F a diagnosis of renal disease. The lab results occur as a result of metabolic acidosis. The nurse
2. The client's WBC count remains within normal indicate a ratio of BUN to creatinine of 15:1. The would expect to note Kussmaul's respirations as a
limits. nurse determines that this result indicates: result of the metabolic acidosis because the
3. The client washes hands at least once per day. 1. A fluid volume deficit bodily response is to exhale excess carbon
4. The client states to avoid blood pressure 2. Liver failure dioxide. Options 1, 2, and 3 are not characteristic
measurement in the left arm. 3. A fluid volume excess of ARF.
2. General indicators that the client is not 4. A normal ratio
experiencing infection include a temperature and 4. The normal ratio of BUN to creatinine is A nursing student is assigned to care for a client
WBC count within normal limits. The client also approximately 10:1 to 15:1. A value lower than with a diagnosis of acute renal failure, diuretic
should use proper hand-washing technique as a 10:1 would indicate diminished urea phase. The nursing instructor asks the student
general preventive measure. Hand washing once concentration. A value greater than 15:1 would about the primary goal of the treatment plan for
per day is insufficient. It is true that the client indicate inadequate renal function. this client. Which of the following statements if
should avoid BP measurement in the affected made by the nursing student would indicate an
arm; however, this would relate more closely to A client is schedule for a excretory urogram. adequate understanding of the treatment plan for
the nursing diagnosis risk for injury. Which of the following would the nurse expect to this client?
be prescribed as a component of preparation for 1. Prevent loss of electrolytes.
A nurse is giving general instructions to a client this test? 2. Reduce the urine specific gravity.
receiving hemodialysis. Which of the following 1. NPO status after midnight. 3. Promote the excretion of wastes.
statements would be appropriate for the nurse to 2. Administration of a sedative before the test. 4. Prevent fluid overload
include? 3. Administration of intravenous fluids. 1. In the diuretic phase, fluids and electrolytes are
1. Several types of medications should be 4. Bowel preparation to remove fecal contents. lost in the urine. As a result, the plan of care
withheld on the day of dialysis until after the 4. An excretory urogram is an invasive test that focuses on fluid and electrolyte replacement and
procedure. uses contrast radiopaque dye to assess the ability monitoring. Options 2, 3, and 4 are not the
2. Medications should be double-dosed on the of the kidneys to excrete dye in the urine. Bowel primary concerns in this phase of renal failure.
morning of hemodialysis to prevent loss. preparation is necessary to permit adequate
3. It's acceptable to exceed the fluid restriction on visualization of the kidneys, ureters, and bladder. A nurse instructs a client about continuous
the day before hemodialysis. Options 1, 2, and 3 usually are not components of ambulatory peritoneal dialysis (CAPD). Which of
4. It's acceptable to eat whatever you want on the preparation for this test. the following statements if made by the client
day before hemodialysis. indicates an accurate understanding of CAPD?
1. Many medications are dialyzable, which means A nurse is reviweing the medication record of a 1. A portable hemodialysis machine is used so
they are extracted from the bloodstream during client diagnosed with chronic renal failure (CRF). that I will be able to ambulate during the
dialysis. Therefore, many medications may be The nurse notes that the client is receiving treatment.
withheld on the day of dialysis until after the aluminum hydroxide (Amphojel). The nurse 2. A cycling machine is used so the risk for
procedure. It is not typical for medications to be determines that the purpose of this medication is infection is minimized.
"double-dosed," because there is no way to be to: 3. No machinery is involved, and I can pursue my
certain how much of each medication is cleared 1. Combine with phosphorus and help eliminate usual activities.
by dialysis. Clients receiving hemodialysis are not phosphates from the body. 4. The drainage system can be used once during
routinely taught that it is acceptable to disregard 2. Prevent ulcers. the day and a cycling machine for 3 cycles at
dietary and fluid restrictions. 3. Promote the elimination of potassium from the night.
body. 3. CAPD closely approximates normal renal
A client with chronic renal failure has been on 4. Prevent constipation function, and the client will need to infuse and
dialysis for 3 years. The client is receiving the 1. Aluminum hydroxide binds with phosphate in drain the dialysis solution several times a day. No
usual combination of medications for the disease, the intestines for excretion in the feces, thus machinery is used, and CAPD is a manual
including aluminum hydroxide as a phosphate- lowering phosphorus levels. It can cause procedure.
binding agent. The client now presents with constipation, and it does not promote the
mental cloudiness, dementia, and complaints of elimination of potassium. It may be used in the A nurse tests the urine of a client with acute renal
bone pain. The nurse interprets that these treatment of hyperacidity associated with gastric failure (ARF) with a multitest reagent strip. The
assessment data are compatible with: ulcers, but this is not the purpose of its use in the strip tests highly positive for proteinuria. The
1. Phosphate overdose client with renal failure. nurse analyzes that this result is consistent with
2. Aluminum intoxication which of the following types of renal failure?
3. Advancing uremia A registered nurse is instructing a new nursing 1. Atypical renal failure
4. Folic acid deficiency graduate about hemodialysis. Which statement if 2. Prerenal failure
2. Aluminum intoxication can occur when there is made by the new nursing graduate would indicate 3. Intrinsic renal failure
accumulation of aluminum, an ingredient in many an inaccurate understanding of the procedure for 4. Postrenal failure
phosphate-binding antacids. It results in mental hemodialysis? 3. With intrinsic renal failure, there is a fixed
cloudiness, dementia, and bone pain from 1. Sterile dialysate must be used. specific gravity and the urine tests definitely
infiltration of the bone with aluminum. It may be 2. Warming the dialysate increases the efficiency positive for proteinuria. In prerenal failure, the
treated with aluminum-chelating agents, which of diffusion. specific gravity is high, and there is very little or
make aluminum available to be dialyzed from the 3. Heparin sodium is administered during dialysis. no proteinuria. In postrenal failure, there is a fixed
specific gravity and little or no proteinuria. There knowing that which finding indicates the child is A child is scheduled for a tonsillectomy in a day
is no disorder known as atypical renal failure. bleeding? surgical unit. On the day after surgery, the mother
Frequent swallowing calls the surgical unit and expresses concern
A client with chronic renal failure is about to begin because the child has a bad mouth odor. Which
hemodialysis therapy. The client asks the nurse Tonsillectomy is the surgical removal of the response is most appropriate?
about the frequency and scheduling of tonsils. Frequent swallowing, restlessness, a fast "Bad mouth odor is normal and may be relieved
hemodialysis treatments. The nurse's response is and thready pulse, and vomiting bright red blood by drinking more liquids."
based on an understanding that the typical are signs of bleeding. An elevated blood pressure
schedule is: and complaints of discomfort are not indications An ambulatory care nurse is preparing a list of
1. 5 hours of treatment 2 days per week. of bleeding. instructions for the parents of a child who is being
2. 3 to 4 hours of treatment 3 days per week discharged after a tonsillectomy. The nurse
3. 2 to 3 hours of treatment 5 days per week A 10-year-old child with asthma is treated for should place which instruction(s) on the list?
4. 2 hours of treatment 6 days per week acute exacerbation in the emergency department. Select all that apply
2. The typical schedule for hemodialysis is 3 to 4 The nurse caring for the child should monitor for Avoid hot fluids.
hours of treatment three days per week. Individual which sign, knowing that it indicates a worsening Avoid raw vegetables.
adjustments may be made according to variables of the condition? Rest in bed or on a couch for 24 hours.
such as the size of the client, type of dialyzer, the Decreased wheezing
rate of blood flow, personal client preferences, The nurse in the ambulatory care unit is caring for
and others. The mother of an 8-year-old child being treated a child after a tonsillectomy. The child's mother
for right lower lobe pneumonia at home calls the tells the nurse that the child is complaining of a
After a tonsillectomy, a child begins to vomit clinic nurse. The mother tells the nurse that the dry throat and would like something to relieve the
bright red blood. The nurse should take which child complains of discomfort on the right side and dryness. Which item should the nurse provide for
initial action? that ibuprofen (Motrin IB) is not effective. Which the mother to give to the child?
Turn the child to the side. instruction should the nurse provide to the Yellow noncitrus Jell-O
mother?
After tonsillectomy, if bleeding occurs, the nurse Encourage the child to lie on the right side. After tonsillectomy, clear, cool liquids should be
immediately turns the child to the side to prevent given. Citrus, carbonated, and extremely hot or
aspiration and then notifies the health care The clinic nurse is providing instructions to a cold liquids should be avoided because they may
provider. NPO status would be maintained, and parent of a child with cystic fibrosis regarding the irritate the throat. Milk and milk products,
an antiemetic may be prescribed; however, the immunization schedule for the child. Which including pudding, are avoided because they coat
initial nursing action would be to turn the child to statement should the nurse make to the parent? the throat, which causes the child to clear the
the side. "The child will receive the recommended basic throat, thereby increasing the risk of bleeding.
series of immunizations along with a yearly Red liquids should be avoided because they give
The nurse is reviewing the laboratory results for a influenza vaccination." the appearance of blood if the child vomits.
child scheduled for tonsillectomy. The nurse
determines that which laboratory value is most The emergency department nurse is caring for a A mother arrives at the hospital emergency
significant to review? child diagnosed with epiglottitis. In assessing the department with her child, in whom a diagnosis of
Prothrombin time child, the nurse should monitor for which epiglottitis is documented. Which prescription, if
indication that the child may be experiencing written by the health care provider, should the
A tonsillectomy is the surgical removal of the airway obstruction? nurse question?
tonsils. Because the tonsillar area is so vascular, The child is leaning forward, with the chin thrust Obtain a throat culture.
postoperative bleeding is a concern. Prothrombin out.
time, partial thromboplastin time, platelet count, The throat of a child with suspected epiglottitis
hemoglobin and hematocrit, white blood cell A child with laryngotracheobronchitis (croup) is should not be examined or cultured because any
count, and urinalysis are performed placed in a cool mist tent. The mother becomes stimulation with a tongue depressor or culture
preoperatively. The prothrombin time results concerned because the child is frightened, swab could cause laryngospasm, thus completing
would identify a potential for bleeding. Creatinine consistently crying and trying to climb out of the airway obstruction. Humidified oxygen and
level, sedimentation rate, and blood urea nitrogen tent. Which is the most appropriate nursing antipyretics are components of management.
would not determine the potential for bleeding. action? Axillary rather than oral temperatures should be
Let the mother hold the child and direct the cool taken to avoid stimulation and resultant
The nurse is preparing to care for a child after a mist over the child's face. laryngospasm.
tonsillectomy. The nurse documents on the plan
of care to place the child in which position? The mother of a hospitalized 2-year-old child with The student nurse is caring for an infant with a
Side-lying- helps facilitate drainage viral laryngotracheobronchitis (croup) asks the tracheostomy and preparing to suction the infant.
nurse why the health care provider did not The nursing instructor should intervene if the
A tonsillectomy is the surgical removal of the prescribe antibiotics. Which response should the nursing student stated she would take which
tonsils. The child should be placed in a prone or nurse make? action to perform this procedure?
side-lying position after the surgical procedure to Antibiotics are not indicated unless a bacterial Limit insertion and suctioning time to 15 seconds
facilitate drainage. infection is present." to prevent hypoxia.

After a tonsillectomy, the nurse reviews the health The nurse is caring for an infant with bronchiolitis, Breathing exercises and postural drainage are
care provider's (HCP's) postoperative and diagnostic tests have confirmed respiratory prescribed for a hospitalized child with cystic
prescriptions. Which prescription should the nurse syncytial virus (RSV). On the basis of this finding, fibrosis (CF). What instruction should the nurse
question? which is the most appropriate nursing action? include in the client's teaching plan?
Suction every 2 hours.-- suctioning is not Move the infant to a room with another child with Perform the postural drainage first and then the
performed unless there is an airway obstruction RSV. breathing exercises.
as unnecessary suctioning can injure the surgery
site. The nurse is preparing for the admission of an The postural drainage will mobilize secretions,
infant with a diagnosis of bronchiolitis caused by and the breathing exercises will then assist with
A tonsillectomy is the surgical removal of the respiratory syncytial virus (RSV). Which expectoration.
tonsils. After tonsillectomy, suction equipment interventions should the nurse include in the plan
should be available, but suctioning is not of care? Select all that apply. A school nurse is teaching parents about
performed unless there is an airway obstruction Place the infant in a private room. emergency treatment for epistaxis. Which best
because of the risk of trauma to the surgical site. Ensure that nurses caring for the infant with RSV action should the nurse take to assist the parents
Monitoring for bleeding is an important nursing do not care for other high-risk children. in understanding the emergency treatment?
intervention after any type of surgery. Milk and Ask the parents to demonstrate, on a mannequin,
milk products are avoided initially because they A child is scheduled for a tonsillectomy. A nurse where to apply continuous pressure if a
coat the throat, cause the child to clear the throat, plans care, knowing that which condition would be nosebleed occurs.
and increase the risk of bleeding. Clear, cool a priority because it presents the highest risk of
liquids are encouraged. aspiration during surgery? A mother arrives at the clinic with her 3-year-old
Presence of loose teeth child. The mother tells the nurse that the child has
The nurse is caring for a child after a had a fever and a cough for the past 2 days and
tonsillectomy. The nurse monitors the child, that this morning the child began to wheeze. Viral
pneumonia is diagnosed. Based on the diagnosis, A nurse is caring for a hospitalized infant with a Epididymitis may occur because of ____ to the
the nurse anticipates that which will be a diagnosis of bronchiolitis. In which position should testicle.
component of the treatment plan? the nurse place the infant? trauma
Supportive treatment Head and chest at a 30-degree angle with the
neck slightly extended A patient has had a tubal insufflation Rubin's test
With viral pneumonia, treatment is supportive. to check whether her fallopian tubes are patent.
More severely ill children may be hospitalized and The nurse should position the infant with the head She complains of pain in her right shoulder. The
given oxygen, chest physiotherapy, and IV fluids. and the chest at a 30- to 40-degree angle with the nurse's most appropriate response would be
Antibiotics are not given. Bacterial pneumonia, neck slightly extended to maintain an open airway "That is from the carbon dioxide passing from the
however, is treated with antibiotic therapy. and to decrease pressure of the diaphragm fallopian tubes into your abdomen."

The mother of a child with cystic fibrosis (CF) A nurse is providing instructions to the mother of Rubin's insufflation test determines
asks the clinic nurse about the disease. What a child with croup regarding treatment measures if fallopian tubal patency.
should the nurse tell the mother about CF? an acute spasmodic episode occurs. Which
A chronic multisystem disorder affecting the statement made by the mother indicates a need The recommended age for a baseline
exocrine glands for further teaching? mammogram is between
"I should place a steam vaporizer in my child's 35 and 39 years.
CF is a chronic multisystem disorder that affects room."
the exocrine glands. The mucus produced by Female infertility is most often related to
these glands (particularly those of the Cool mist humidifiers are recommended over infections of the reproductive tract.
bronchioles, small intestine, and pancreatic and steam vaporizers, which present a danger of
bile ducts) is abnormally thick, causing scald burns. Steam from running water in a Sexual transmission of HPV genital herpes, a
obstruction of the small passageways of these closed bathroom or from a vaporizer will assist in virus, has been documented even in the absence
organs. It is transmitted as an autosomal keeping secretions thin so that they can be easily of clinical lesions, and the use of
recessive trait. expectorated condoms should be encouraged.

A mother calls the pediatrician's office requesting The nurse employed in an emergency department If severe or chronic pelvic inflammatory disease is
an appointment for her 8-year-old child. She is monitoring a child diagnosed with epiglottitis. present, the complication that may result is
states he has asthma and is telling her he had The nurse notes that the child is leaning forward infertility
trouble breathing last night and does not want to with the chin thrust out. How should the nurse
go to school. In triaging this child, which is the interpret this finding? A Gram-stain smear of the patient's discharge
most important question to initially ask the An airway obstruction reveals the presence of N. gonorrhoeae. The
mother? female patient, however, does not feel she
"Is your child telling you at this time he is having clinical manifestations suggestive of airway appears to have any disease.
trouble breathing?" obstruction include tripod positioning (leaning Most women remain asymptomatic but may show
forward supported by arms, chin thrust out, mouth a greenish-yellow discharge from the cervix.
After a tonsillectomy, a child is brought to the open), nasal flaring, tachycardia, a high fever, and
pediatric unit. The nurse should appropriately sore throat. an anterior and posterior colporrhaphy for repair
place the child in which position? of a cystocele and rectocele. what would you
Prone he patient is scheduled for a vaginal expect to find?
hysterectomy. What position will this patient be A retention catheter is usually inserted into the
The child should be placed in a prone or side- placed in? bladder to keep it empty and prevent pressure on
lying position after tonsillectomy to facilitate a lithotomy position, and the uterus is removed sutures.
drainage through the vagina.
A mammogram is the most useful method of
A pediatric nurse in the ambulatory surgery unit is On the second postoperative day, a patient who diagnosing breast cancer because it
caring for a child following a tonsillectomy. The has had an abdominal hysterectomy complains of is the most reliable method of detecting breast
child is complaining of a dry throat. Which item gas pains and abdominal distention. Which cancer before it becomes palpable.
should the nurse offer to the child? intervention will best stimulate peristalsis and
Green gelatin relieve distention? The patient is recovering from a modified radical
Encouraging ambulation at least four times per mastectomy. After this procedure, the
A nurse is reviewing the health care provider's day postoperative elevation of a patient's arm with
prescriptions for a child following a tonsillectomy. proper positioning is important to prevent
Which prescription should the nurse question? A patient tells the nurse that his wife, who has vascular and lymph stasis, thus lymphedema.
Suction the child frequently if coughing. been diagnosed with inoperable ovarian cancer,
is talking about dying and fear of death. A patient is recovering from an abdominal
During clinical conference, a nursing student is "It is perfectly normal to want to talk about death. hysterectomy. Postoperative nursing interventions
discussing care for a child with a diagnosis of It is most helpful to support her by listening." for her would include
cystic fibrosis (CF). Which comment by a student preventing urinary retention.
indicates the need for further review of A total abdominal hysterectomy with bilateral
information about cystic fibrosis? salpingo-oophorectomy is the removal of the Postmenopausal women should be instructed to
This disease causes dilation of the passageways uterus, fallopian tubes (salpingectomy), and perform breast self-examination (BSE)
of many organs. ovaries (oophorectomy) on the same date of their choice each month.
If the ovaries are removed in these surgeries, the
A nurse has provided instructions to the mother of surgery will induce menopause and hot flashes If there has been an abdominal incision, there
a child with cystic fibrosis (CF) about appropriate may occur. may be further restrictions
dietary measures. Which statement by the mother to not lift anything over 10lbs
indicates an understanding of these dietary Patients who have undergone a modified radical
measures? mastectomy should be instructed to avoid An appropriate nursing intervention for the patient
The diet needs to be high in calories." sleeping with a hydrocele is to
on the involved arm. An exercise regimen, built up apply ice packs.
Children with CF are managed with a high-calorie, gradually, can help reduce lymphedema.
high-protein diet. Pancreatic enzyme replacement hydrocele
therapy and water-soluble vitamin supplements outstanding sign she should report that might
(A, D, E, and K) are administered. If nutritional indicate toxic shock syndrome
problems are severe, supplemental tube feedings sudden elevated temperature orchiectomy
or parenteral nutrition is administered. Fats are surgical procedure in which one or both testicles
not restricted unless steatorrhea cannot be At what age should a male be taught testicular are removed
controlled by administration of increased self-exam [TSE]?
pancreatic enzymes 13. Perform TSE after a bath or shower when A patient is scheduled for a unilateral orchiectomy
scrotum is warm and most relaxed. The testes for treatment of testicular cancer. He is withdrawn
should feel smooth and be firm to touch. and does not initiate interaction with the nurse.
Which action is most appropriate?
Assess his concerns related to his diagnosis and a. vesicular breath sounds. for aspiration in patients at risk. Monitoring of
treatment. b. increased tactile fremitus. parameters such as breath sounds and oxygen
c. dry, nonproductive cough. saturation will help detect pneumonia in
During physical assessment of a patient, age 64, d. hyperresonance to percussion. immunocompromised patients, but it will not
which finding would the nurse consider abnormal? ANS: B decrease the risk for aspiration. Continuous
Serous nipple drainage Increased tactile fremitus over the area of subglottic suction is recommended for intubated
pulmonary consolidation is expected with patients but not for all patients receiving enteral
A patient seeks care because he has developed a bacterial pneumonias. Dullness to percussion feedings.
profuse, purulent urethral discharge, and urination would be expected. Pneumococcal pneumonia
is painful. It is most important that the nurse typically presents with a loose, productive cough. DIF: Cognitive Level: Application REF: 551
gather information related to Adventitious breath sounds such as crackles and TOP: Nursing Process: Implementation MSC:
a history of recent sexual contact with an wheezes are typical. NCLEX: Physiological Integrity
individual with a sexually transmitted disease.
DIF: Cognitive Level: Application REF: 549 After a patient with right lower-lobe pneumonia
Which statement by the patient/family indicates TOP: Nursing Process: Assessment MSC: has been treated with intravenous (IV) antibiotics
that more teaching about HPV is necessary? NCLEX: Physiological Integrity for 2 days, which assessment data obtained by
"I understand I don't need to get the new HPV the nurse indicates that the treatment has been
vaccine unless I am sexually active." A patient with bacterial pneumonia has rhonchi effective?
and thick sputum. Which action will the nurse use a. Bronchial breath sounds are heard at the right
During a laparoscopy, a small incision is made to promote airway clearance? base.
beneath the umbilicus to view the abdominal a. Assist the patient to splint the chest when b. The patient coughs up small amounts of green
cavity. What is the purpose of insertion of a Foley coughing. mucus.
catheter into the bladder? b. Educate the patient about the need for fluid c. The patient's white blood cell (WBC) count is
Maintain bladder decompression for an open view restrictions. 9000/µl.
c. Encourage the patient to wear the nasal d. Increased tactile fremitus is palpable over the
laparoscopy oxygen cannula. right chest.
d. Instruct the patient on the pursed lip breathing ANS: C
technique. The normal WBC count indicates that the
What factor influences older women's reluctance ANS: A antibiotics have been effective. All the other data
to seek medical care for problems of the Coughing is less painful and more likely to be suggest that a change in treatment is needed.
reproductive system? effective when the patient splints the chest during
Embarrassment and cultural factors coughing. Fluids should be encouraged to help DIF: Cognitive Level: Application REF: 549 TOP:
liquefy secretions. Nasal oxygen will improve gas Nursing Process: Evaluation
False negative results in mammography occur in exchange, but will not improve airway clearance. MSC: NCLEX: Physiological Integrity
specific age groups because: Pursed lip breathing is used to improve gas
younger women have greater density of breast exchange in patients with COPD, but will not The health care provider writes an order for
tissue. improve airway clearance. bacteriologic testing for a patient who has a
positive tuberculosis skin test. Which action will
Vaginal fistulas are caused by an ulcerating DIF: Cognitive Level: Application REF: 552-553 the nurse take?
process resulting from TOP: Nursing Process: Implementation MSC: a. Repeat the tuberculin skin testing.
cancer NCLEX: Physiological Integrity b. Teach about the reason for the blood tests.
radiation c. Obtain consecutive sputum specimens from the
weakening of tissue from pregnancies Which statement by a patient who has been patient for 3 days.
surgical interventions hospitalized for pneumonia indicates a good d. Instruct the patient to expectorate three
understanding of the discharge instructions given specimens as soon as possible.
Select the interventions that should not be by the nurse? ANS: C
performed with in the affected arm of patients who a. "I will call the doctor if I still feel tired after a Three consecutive sputum specimens are
have undergone a modified radical mastectomy. week." obtained on different days for bacteriologic testing
vaccinations b. "I will need to use home oxygen therapy for 3 for M. tuberculosis. The patient should not provide
BP readings months." all the specimens at once. Blood cultures are not
insertion of I.V. lines c. "I will continue to do the deep breathing and used for tuberculosis testing. Once skin testing is
coughing exercises at home." positive, it is not repeated.
The nurse is assisting the physician in removing a d. "I will schedule two appointments for the
small sample of tissue from the patient's cervix to pneumonia and influenza vaccines." DIF: Cognitive Level: Application REF: 555
have it evaluated. This procedure is called a ANS: C TOP: Nursing Process: Implementation MSC:
cervical _______________. Patients should continue to cough and deep NCLEX: Physiological Integrity
conization breathe after discharge. Fatigue for several
weeks is expected. Home oxygen therapy is not Which information about a patient who has a
_____________ are benign tumors of the uterus. needed with successful treatment of pneumonia. recent history of tuberculosis (TB) indicates that
Fibroids The pneumovax and influenza vaccines can be the nurse can discontinue airborne isolation
given at the same time. precautions?
Following assessment of a patient with a. Chest x-ray shows no upper lobe infiltrates.
pneumonia, the nurse identifies a nursing DIF: Cognitive Level: Application REF: 552 TOP: b. TB medications have been taken for 6 months.
diagnosis of ineffective airway clearance. Which Nursing Process: Evaluation c. Mantoux testing shows an induration of 10 mm.
information best supports this diagnosis? MSC: NCLEX: Physiological Integrity d. Three sputum smears for acid-fast bacilli are
a. Weak, nonproductive cough effort negative.
b. Large amounts of greenish sputum Which nursing action will be most effective in ANS: D
c. Respiratory rate of 28 breaths/minute preventing aspiration pneumonia in patients who Negative sputum smears indicate that M.
d. Resting pulse oximetry (SpO2) of 85% are at risk? tuberculosis is not present in the sputum, and the
ANS: A a. Turn and reposition immobile patients at least patient cannot transmit the bacteria by the
The weak, nonproductive cough indicates that the every 2 hours. airborne route. Chest x-rays are not used to
patient is unable to clear the airway effectively. b. Place patients with altered consciousness in determine whether treatment has been
The other data would be used to support side-lying positions. successful. Taking medications for 6 months is
diagnoses such as impaired gas exchange and c. Monitor for respiratory symptoms in patients necessary, but the multidrug-resistant forms of
ineffective breathing pattern. who are immunosuppressed. the disease might not be eradicated after 6
d. Provide for continuous subglottic aspiration in months of therapy. Repeat Mantoux testing would
DIF: Cognitive Level: Application REF: 551-552 patients receiving enteral feedings. not be done since it will not change even with
TOP: Nursing Process: Diagnosis ANS: B effective treatment.
MSC: NCLEX: Physiological Integrity The risk for aspiration is decreased when patients
with a decreased level of consciousness are DIF: Cognitive Level: Application REF: 557
During assessment of the chest in a patient with placed in a side-lying or upright position. Frequent TOP: Nursing Process: Implementation MSC:
pneumococcal pneumonia, the nurse would turning prevents pooling of secretions in NCLEX: Physiological Integrity
expect to find immobilized patients but will not decrease the risk
The nurse recognizes that the goals of teaching be appropriate for some patients, but are not bringing food from outside the hospital is
regarding the transmission of pulmonary likely to be as helpful with this patient. appropriate. The family member should wash the
tuberculosis (TB) have been met when the patient hands after handling a tissue that the patient has
with TB DIF: Cognitive Level: Application REF: 556 used, but no precautions are necessary when
a. demonstrates correct use of a nebulizer. TOP: Nursing Process: Implementation MSC: giving the patient an unused tissue.
b. washes dishes and personal items after use. NCLEX: Physiological Integrity
c. covers the mouth and nose when coughing. DIF: Cognitive Level: Application REF: 557
d. reports daily to the public health department. After 2 months of tuberculosis (TB) treatment with TOP: Nursing Process: Implementation MSC:
ANS: C a standard four-drug regimen, a patient continues NCLEX: Physiological Integrity
Covering the mouth and nose will help decrease to have positive sputum smears for acid-fast
airborne transmission of TB. The other actions will bacilli (AFB). Which action should the nurse take Which action by the occupational health nurse at
not be effective in decreasing the spread of TB. next? a manufacturing plant where there is potential
a. Ask the patient whether medications have been exposure to inhaled dust will be most helpful in
DIF: Cognitive Level: Application REF: 557 TOP: taken as directed. reducing incidence of lung disease?
Nursing Process: Evaluation b. Discuss the need to use some different a. Teach about symptoms of lung disease.
MSC: NCLEX: Health Promotion and medications to treat the TB. b. Treat workers who inhale dust particles.
Maintenance c. Schedule the patient for directly observed c. Monitor workers for shortness of breath.
therapy three times weekly. d. Require the use of protective equipment.
Which information will the nurse include in the d. Educate about using a 2-drug regimen for the ANS: D
patient teaching plan for a patient who is receiving last 4 months of treatment. Prevention of lung disease requires the use of
rifampin (Rifadin) for treatment of tuberculosis? ANS: A appropriate protective equipment such as masks.
a. "Your urine, sweat, and tears will be orange The first action should be to determine whether The other actions will help in recognition or early
colored." the patient has been compliant with drug therapy treatment of lung disease, but will not be effective
b. "Read a newspaper daily to check for changes because negative sputum smears would be in prevention of lung damage.
in vision." expected if the TB bacillus is susceptible to the
c. "Take vitamin B6 daily to prevent peripheral medications and if the medications have been DIF: Cognitive Level: Application REF: 560-561
nerve damage." taken correctly. Depending on whether the patient TOP: Nursing Process: Assessment MSC:
d. "Call the health care provider if you notice any has been compliant or not, different medications NCLEX: Health Promotion and Maintenance
hearing loss." or directly observed therapy may be indicated. A
ANS: A two-drug regimen will be used only if the sputum When developing a teaching plan for a patient
Orange-colored body secretions are a side effect smears are negative for AFB. with a 42 pack-year history of cigarette smoking, it
of rifampin. The other adverse effects are will be most important for the nurse to include
associated with other antituberculosis DIF: Cognitive Level: Application REF: 556-557 information about
medications. TOP: Nursing Process: Implementation MSC: a. computed tomography (CT) screening for lung
NCLEX: Physiological Integrity cancer.
DIF: Cognitive Level: Application REF: 555 TOP: b. options for smoking cessation.
Nursing Process: Planning A staff nurse has a tuberculosis (TB) skin test of c. reasons for annual sputum cytology testing.
MSC: NCLEX: Physiological Integrity 16-mm induration. A chest radiograph is negative, d. erlotinib (Tarceva) therapy to prevent tumor
and the nurse has no symptoms of TB. The risk.
When teaching the patient who is receiving occupational health nurse will plan on teaching ANS: B
standard multidrug therapy for tuberculosis (TB) the staff nurse about the Because smoking is the major cause of lung
about possible toxic effects of the antitubercular a. use and side effects of isoniazid (INH). cancer, the most important role for the nurse is
medications, the nurse will give instructions to b. standard four-drug therapy for TB. educating patients about the benefits of and
notify the health care provider if the patient c. need for annual repeat TB skin testing. means of smoking cessation. Early screening of
develops d. bacille Calmette-Guérin (BCG) vaccine. at-risk patients using sputum cytology, chest x-
a. yellow-tinged skin. ANS: A ray, or CT scanning has not been effective in
b. changes in hearing. The nurse is considered to have a latent TB reducing mortality. Erlotinib may be used in
c. orange-colored sputum. infection and should be treated with INH daily for patients who have lung cancer but not to reduce
d. thickening of the fingernails. 6 to 9 months. The four-drug therapy would be risk for developing tumors.
ANS: A appropriate if the nurse had active TB. TB skin
Noninfectious hepatitis is a toxic effect of testing is not done for individuals who have DIF: Cognitive Level: Application REF: 563 | 565
isoniazid (INH), rifampin, and pyrazinamide, and already had a positive skin test. BCG vaccine is TOP: Nursing Process: Planning
patients who develop hepatotoxicity will need to not used in the United States and would not be MSC: NCLEX: Health Promotion and
use other medications. Changes in hearing and helpful for this individual, who already has a TB Maintenance
nail thickening are not expected with the four infection.
medications used for initial TB drug therapy. A lobectomy is scheduled for a patient with stage
Orange discoloration of body fluids is an expected DIF: Cognitive Level: Application REF: 556-557 I non-small cell lung cancer. The patient tells the
side effect of rifampin and not an indication to call TOP: Nursing Process: Planning nurse, "I would rather have radiation than
the health care provider. MSC: NCLEX: Health Promotion and surgery." Which response by the nurse is most
Maintenance appropriate?
DIF: Cognitive Level: Application REF: 555 | 556 a. "Are you afraid that the surgery will be very
TOP: Nursing Process: Implementation MSC: When caring for a patient who is hospitalized with painful?"
NCLEX: Physiological Integrity active tuberculosis (TB), the nurse observes a b. "Did you have bad experiences with previous
family member who is visiting the patient. The surgeries?"
An alcoholic and homeless patient is diagnosed nurse will need to intervene if the family member c. "Surgery is the treatment of choice for stage I
with active tuberculosis (TB). Which intervention a. washes the hands before entering the patient's lung cancer."
by the nurse will be most effective in ensuring room. d. "Tell me what you know about the various
adherence with the treatment regimen? b. hands the patient a tissue from the box at the treatments available."
a. Educating the patient about the long-term bedside. ANS: D
impact of TB on health c. puts on a surgical face mask before visiting the More assessment of the patient's concerns about
b. Giving the patient written instructions about patient. surgery is indicated. An open-ended response will
how to take the medications d. brings food from a "fast-food" restaurant to the elicit the most information from the patient. The
c. Teaching the patient about the high risk for patient. answer beginning, "Surgery is the treatment of
infecting others unless treatment is followed ANS: C choice" is accurate, but it discourages the patient
d. Arranging for a daily noontime meal at a A high-efficiency particulate-absorbing (HEPA) from sharing concerns about surgery. The
community center and giving the medication then mask, rather than a standard surgical mask, remaining two answers indicate that the nurse
ANS: D should be used when entering the patient's room has jumped to conclusions about the patient's
Directly observed therapy is the most effective because the HEPA mask can filter out 100% of reasons for not wanting surgery.
means for ensuring compliance with the treatment small airborne particles. Hand washing before
regimen, and arranging a daily meal will help to visiting the patient is not necessary, but there is DIF: Cognitive Level: Application REF: 565
ensure that the patient is available to receive the no reason for the nurse to stop the family member TOP: Nursing Process: Implementation MSC:
medication. The other nursing interventions may from doing this. Because anorexia and weight NCLEX: Psychosocial Integrity
loss are frequent problems in patients with TB,
An hour after a thoracotomy, a patient complains b. the complaint of chest wall pain. MSC: NCLEX: Physiological Integrity
of incisional pain at a level 7 out of 10 and has c. a heart rate of 110 beats/minute.
decreased left-sided breath sounds. The pleural d. a large bruised area on the chest. To determine the effectiveness of prescribed
drainage system has 100 mL of bloody drainage ANS: A therapies for a patient with cor pulmonale and
and a large air leak. Which action is best for the Paradoxic chest movement indicates that the right-sided heart failure, which assessment will
nurse to take next? patient may have flail chest, which can severely the nurse make?
a. Administer the prescribed PRN morphine. compromise gas exchange and can rapidly lead a. Lung sounds
b. Assist the patient to deep breathe and cough. to hypoxemia. Chest wall pain, a slightly elevated b. Heart sounds
c. Milk the chest tube gently to remove any clots. pulse rate, and chest bruising all require further c. Blood pressure
d. Tape the area around the insertion site of the assessment or intervention, but the priority d. Peripheral edema
chest tube. concern is poor gas exchange. ANS: D
ANS: A Cor pulmonale is right ventricular failure caused
The patient is unlikely to take deep breaths or DIF: Cognitive Level: Application REF: 567 | 569 by pulmonary hypertension, so clinical
cough until the pain level is lower. A chest tube TOP: Nursing Process: Assessment MSC: manifestations of right ventricular failure such as
output of 100 mL is not unusual in the first hour NCLEX: Physiological Integrity peripheral edema, jugular vein distention, and
after thoracotomy and would not require milking of right upper-quadrant abdominal tenderness would
the chest tube. An air leak is expected in the initial When assessing a 24-year-old patient who has be expected. Abnormalities in lung sounds, blood
postoperative period after thoracotomy. just arrived after an automobile accident, the pressure, or heart sounds are not caused by cor
emergency department nurse notes that the pulmonale.
DIF: Cognitive Level: Application REF: 573-574 breath sounds are absent on the right side. The
TOP: Nursing Process: Implementation MSC: nurse will anticipate the need for DIF: Cognitive Level: Application REF: 582 TOP:
NCLEX: Physiological Integrity a. emergency pericardiocentesis. Nursing Process: Evaluation
b. stabilization of the chest wall with tape. MSC: NCLEX: Physiological Integrity
A patient with newly diagnosed lung cancer tells c. administration of an inhaled bronchodilator.
the nurse, "I think I am going to die pretty soon." d. insertion of a chest tube with a chest drainage A patient with primary pulmonary hypertension
Which response by the nurse is best? system. (PPH) is receiving nifedipine (Procardia). The
a. "Would you like to talk to the hospital chaplain ANS: D nurse will evaluate that the treatment is effective if
about your feelings?" The patient's history and absent breath sounds a. the BP is less than 140/90 mm Hg.
b. "Can you tell me what it is that makes you think suggest a right-sided pneumothorax or b. the patient reports decreased exertional
you will die so soon?" hemothorax, which will require treatment with a dyspnea.
c. "Are you afraid that the treatment for your chest tube and drainage. The other therapies c. the heart rate is between 60 and 100
cancer will not be effective?" would be appropriate for an acute asthma attack, beats/minute.
d. "Do you think that taking an antidepressant flail chest, or cardiac tamponade, but the patient's d. the patient's chest x-ray indicates clear lung
medication would be helpful?" clinical manifestations are not consistent with fields.
ANS: B these problems. ANS: B
The nurse's initial response should be to collect Since a major symptom of PPH is exertional
more assessment data about the patient's DIF: Cognitive Level: Application REF: 567 TOP: dyspnea, an improvement in this symptom would
statement. The answer beginning "Can you tell Nursing Process: Planning indicate that the medication was effective.
me what it is" is the most open-ended question MSC: NCLEX: Physiological Integrity Nifedipine will affect BP and heart rate, but these
and will offer the best opportunity for obtaining parameters would not be used to monitor
more data. The answer beginning, "Are you A patient who has a right-sided chest tube effectiveness of therapy for a patient with PPH.
afraid" implies that the patient thinks that the following a thoracotomy has continuous bubbling The chest x-ray will show clear lung fields even if
cancer will be immediately fatal, although the in the suction-control chamber of the collection the therapy is not effective.
patient's statement may not be related to the device. The most appropriate action by the nurse
cancer diagnosis. The remaining two answers is to DIF: Cognitive Level: Application REF: 582 TOP:
offer interventions that may be helpful to the a. document the presence of a large air leak. Nursing Process: Evaluation
patient, but more assessment is needed to b. obtain and attach a new collection device. MSC: NCLEX: Physiological Integrity
determine whether these interventions are c. notify the surgeon of a possible pneumothorax.
appropriate. d. take no further action with the collection device. A patient with a pleural effusion is scheduled for a
ANS: D thoracentesis. Before the procedure, the nurse
DIF: Cognitive Level: Application REF: 565 Continuous bubbling is expected in the suction- will plan to
TOP: Nursing Process: Implementation MSC: control chamber and indicates that the suction- a. start a peripheral intravenous line to administer
NCLEX: Psychosocial Integrity control chamber is connected to suction. An air the necessary sedative drugs.
leak would be detected in the water-seal b. position the patient sitting upright on the edge
The health care provider inserts a chest tube in a chamber. There is no evidence of pneumothorax. of the bed and leaning forward.
patient with a hemopneumothorax. When A new collection device is needed when the c. remove the water pitcher and remind the
monitoring the patient after the chest tube collection chamber is filled. patient not to eat or drink anything for 6 hours.
placement, the nurse will be most concerned d. instruct the patient about the importance of
about DIF: Cognitive Level: Application REF: 572 incentive spirometer use after the procedure.
a. a large air leak in the water-seal chamber. TOP: Nursing Process: Implementation MSC: ANS: B
b. 400 mL of blood in the collection chamber. NCLEX: Physiological Integrity When the patient is sitting up, fluid accumulates in
c. complaint of pain with each deep inspiration. the pleural space at the lung bases and can more
d. subcutaneous emphysema at the insertion site. When providing preoperative instruction for a easily be located and removed. The lung will
ANS: B patient scheduled for a left pneumonectomy for expand after the effusion is removed; incentive
The large amount of blood may indicate that the cancer of the lung, the nurse informs the patient spirometry is not needed to assure alveolar
patient is in danger of developing hypovolemic that the postoperative care includes expansion. The patient does not usually require
shock. A large air leak would be expected a. positioning on the right side. sedation for the procedure, and there are no
immediately after chest tube placement for b. bed rest for the first 24 hours. restrictions on oral intake because the patient is
pneumothorax. The pain should be treated but is c. frequent use of an incentive spirometer. not sedated or unconscious.
not as urgent a concern as the possibility of d. chest tubes to water-seal chest drainage.
continued hemorrhage. Subcutaneous ANS: C DIF: Cognitive Level: Application REF: 576 TOP:
emphysema should be monitored but is not Frequent deep breathing and coughing are Nursing Process: Planning
unusual in a patient with pneumothorax. needed after chest surgery to prevent atelectasis. MSC: NCLEX: Physiological Integrity
To promote gas exchange, patients after
DIF: Cognitive Level: Application REF: 572 pneumonectomy are positioned on the surgical After discharge teaching has been completed for
TOP: Nursing Process: Assessment MSC: side. Chest tubes are not usually used after a patient who has had a lung transplant, the nurse
NCLEX: Physiological Integrity pneumonectomy because the affected side is will evaluate that the teaching has been effective
allowed to fill with fluid. Early mobilization if the patient states
A patient experiences a steering wheel injury as a decreases the risk for postoperative complications a. "I will make an appointment to see the doctor
result of an automobile accident. During the initial such as pneumonia and deep vein thrombosis. every year."
assessment, the emergency department nurse b. "I will not turn the home oxygen up higher than
would be most concerned about DIF: Cognitive Level: Application REF: 573 TOP: 2 L/minute."
a. paradoxic chest movement. Nursing Process: Planning
c. "I will not worry if I feel a little short of breath immunodeficiency virus (HIV) and active DIF: Cognitive Level: Application REF: 580
with exercise." tuberculosis (TB) disease is most important to OBJ: Special Questions: Prioritization TOP:
d. "I will call the health care provider right away if I communicate to the health care provider? Nursing Process: Implementation
develop a fever." a. The Mantoux test had an induration of only 8 MSC: NCLEX: Physiological Integrity
ANS: D mm.
Low-grade fever may indicate infection or acute b. The chest-x-ray showed infiltrates in the upper After the nurse has received change-of-shift
rejection, so the patient should notify the health lobes. report about the following four patients, which
care provider immediately if the temperature is c. The patient is being treated with antiretrovirals patient should be assessed first?
elevated. Patients require frequent follow-up visits for HIV infection. a. A 77-year-old patient with tuberculosis (TB)
with the transplant team; annual health care d. The patient has a cough that is productive of who has four antitubercular medications due in 15
provider visits would not be sufficient. Home blood-tinged mucus. minutes
oxygen use is not an expectation after lung ANS: C b. A 23-year-old patient with cystic fibrosis who
transplant. Shortness of breath should be Drug interactions can occur between the has pulmonary function testing scheduled
reported. antiretrovirals used to treat HIV infection and the c. A 46-year-old patient who has a deep vein
medications used to treat tuberculosis. The other thrombosis and is complaining of sudden onset
DIF: Cognitive Level: Application REF: 583 TOP: data are expected in a patient with HIV and TB shortness of breath.
Nursing Process: Evaluation disease. d. A 35-year-old patient who was admitted the
MSC: NCLEX: Physiological Integrity previous day with pneumonia and has a
DIF: Cognitive Level: Application REF: 556 temperature of 100.2° F (37.8° C)
Which of these orders will the nurse act on first for OBJ: Special Questions: Prioritization TOP: ANS: C
a patient who has just been admitted with Nursing Process: Assessment Sudden onset shortness of breath in a patient
probable bacterial pneumonia and sepsis? with a deep vein thrombosis suggests a
a. Administer aspirin suppository. A patient with pneumonia has a fever of 101.2° F pulmonary embolism and requires immediate
b. Send to radiology for chest x-ray. (38.5° C), a nonproductive cough, and an oxygen assessment and actions such as oxygen
c. Give ciprofloxacin (Cipro) 400 mg IV. saturation of 89%. The patient is very weak and administration. The other patients also should be
d. Obtain blood cultures from two sites. needs assistance to get out of bed. The priority assessed as soon as possible, but there is no
ANS: D nursing diagnosis for the patient is indication that they may need immediate action to
Initiating antibiotic therapy rapidly is essential, but a. hyperthermia related to infectious illness. prevent clinical deterioration.
it is important that the cultures be obtained before b. impaired transfer ability related to weakness.
antibiotic administration. The chest radiograph c. ineffective airway clearance related to thick DIF: Cognitive Level: Application REF: 577-578
and aspirin administration can be done last. secretions. OBJ: Special Questions: Multiple Patients TOP:
d. impaired gas exchange related to respiratory Nursing Process: Planning
DIF: Cognitive Level: Application REF: 549 congestion. MSC: NCLEX: Physiological Integrity
OBJ: Special Questions: Prioritization TOP: ANS: D
Nursing Process: Implementation All these nursing diagnoses are appropriate for The nurse is performing tuberculosis (TB)
MSC: NCLEX: Physiological Integrity the patient, but the patient's oxygen saturation screening in a clinic that has many patients who
indicates that all body tissues are at risk for have immigrated to the United States. Before
Which assessment information obtained by the hypoxia unless the gas exchange is improved. doing a TB skin test on a patient, which question
nurse when caring for a patient who has just had is most important for the nurse to ask?
a thoracentesis is most important to communicate DIF: Cognitive Level: Application REF: 552-553 a. "Is there any family history of TB?"
to the health care provider? OBJ: Special Questions: Prioritization TOP: b. "Have you received the bacille Calmette-Guérin
a. BP is 150/90 mm Hg. Nursing Process: Diagnosis (BCG) vaccine for TB?"
b. Oxygen saturation is 89%. MSC: NCLEX: Physiological Integrity c. "How long have you lived in the United States?"
c. Pain level is 5/10 with a deep breath. d. "Do you take any over-the-counter (OTC)
d. Respiratory rate is 24 when lying flat. The nurse observes nursing assistive personnel medications?"
ANS: B (NAP) doing all the following activities when ANS: B
Oxygen saturation would be expected to improve caring for a patient with right lower lobe Patients who have received the BCG vaccine will
after a thoracentesis. A saturation of 89% pneumonia. The nurse will need to intervene have a positive Mantoux test. Another method for
indicates that a complication such as when NAP screening (such as a chest x-ray) will need to be
pneumothorax may be occurring. The other a. lower the head of the patient's bed to 10 used in determining whether the patient has a TB
assessment data also indicate a need for ongoing degrees. infection. The other information also may be
assessment or intervention, but the low oxygen b. splint the patient's chest during coughing. valuable but is not as pertinent to the decision
saturation is the priority. c. help the patient to ambulate to the bathroom. about doing TB skin testing.
d. assist the patient to a bedside chair for meals.
DIF: Cognitive Level: Application REF: 576 ANS: A DIF: Cognitive Level: Application REF: 557
OBJ: Special Questions: Prioritization TOP: Positioning the patient with the head of the bed OBJ: Special Questions: Prioritization TOP:
Nursing Process: Assessment lowered will decrease ventilation. The other Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity actions are appropriate for a patient with MSC: NCLEX: Physiological Integrity
pneumonia.
A patient who has just been admitted with A patient is admitted to the emergency
pneumococcal pneumonia has a temperature of DIF: Cognitive Level: Application REF: 552-553 department with an open stab wound to the right
101.6° F with a frequent cough and is OBJ: Special Questions: Delegation TOP: chest. What is the first action that the nurse
complaining of severe pleuritic chest pain. Which Nursing Process: Implementation should take?
of these prescribed medications should the nurse MSC: NCLEX: Safe and Effective Care a. Position the patient so that the right chest is
give first? Environment dependent.
a. guaifenesin (Robitussin) b. Keep the head of the patient's bed at no more
b. acetaminophen (Tylenol) A patient with a possible pulmonary embolism than 30 degrees elevation.
c. azithromycin (Zithromax) complains of chest pain and difficulty breathing. c. Tape a nonporous dressing on three sides over
d. codeine phosphate (Codeine) The nurse finds a heart rate of 142, BP reading of the chest wound.
ANS: C 100/60, and respirations of 42. The nurse's first d. Cover the sucking chest wound firmly with an
Early initiation of antibiotic therapy has been action should be to occlusive dressing.
demonstrated to reduce mortality. The other a. elevate the head of the bed to 45 to 60 ANS: C
medications also are appropriate and should be degrees. The dressing taped on three sides will allow air to
given as soon as possible, but the priority is to b. administer the ordered pain medication. escape when intrapleural pressure increases
start antibiotic therapy. c. notify the patient's health care provider. during expiration, but it will prevent air from
d. offer emotional support and reassurance. moving into the pleural space during inspiration.
DIF: Cognitive Level: Application REF: 549 ANS: A Placing the patient on the right side or covering
OBJ: Special Questions: Prioritization TOP: The patient has symptoms consistent with a the chest wound with an occlusive dressing will
Nursing Process: Implementation pulmonary embolism. Elevating the head of the allow trapped air in the pleural space and cause
MSC: NCLEX: Physiological Integrity bed will improve ventilation and gas exchange. tension pneumothorax. The head of the bed
The other actions can be accomplished after the should be elevated to 30 to 45 degrees to
Which information obtained by the nurse about a head is elevated (and oxygen is started). facilitate breathing.
patient who has been diagnosed with both human
DIF: Cognitive Level: Application REF: 567 Put a comma and space between each answer Answer: D. although smoking is the most
OBJ: Special Questions: Prioritization TOP: choice (a, b, c, d, etc.) ____________________ common cause, low intake of fruits/vegetables,
Nursing Process: Implementation a. Obtain the oxygen saturation. family history, environmental and occupational
MSC: NCLEX: Physiological Integrity b. Check the patient's pulse rate. exposure and second-hand smoke exposure are
c. Document the change in status. also risk factors for lung cancer. Having a history
The nurse notes that a patient has incisional pain, d. Notify the health care provider. of COPD/asthma alone are not considered risk
a poor cough effort, and scattered rhonchi after a ANS: factors for lung cancer.
thoracotomy. Which action should the nurse take A, B, D, C
first? Assessment for physiologic causes of new onset Which of the following clients should the nurse
a. Assist the patient to sit up at the bedside. confusion such as pneumonia, infection, or most likely suspect possible undiagnosed lung
b. Splint the patient's chest during coughing. perfusion problems should be the first action by cancer?
c. Medicate the patient with the prescribed the nurse. Airway and oxygenation should be A) A 54 year old patient with new onset pleuritic
morphine. assessed first, then circulation. After assessing pain
d. Have the patient use the prescribed incentive the patient, the nurse should notify the health B) A 74 year old African American male with a
spirometer. care provider. Finally, documentation of the history of COPD
ANS: C assessments and care should be done. C) A 50 year old patient with repeated upper
A major reason for atelectasis and poor airway respiratory infection
clearance in patients after chest surgery is DIF: Cognitive Level: Analysis REF: 549 | 551 D) An 82 year old patient with productive, purulent
incisional pain (which increases with deep OBJ: Special Questions: Alternate Item Format, cough
breathing and coughing). The first action by the Prioritization Answer: C. Repeated, unresolved upper
nurse should be to medicate the patient to TOP: Nursing Process: Implementation MSC: respiratory infection (often signified by recurring
minimize incisional pain. The other actions are all NCLEX: Physiolog fever) is a common manifestation in a client with
appropriate ways to improve airway clearance but underlying lung cancer. New onset of pleuritic
should be done after the morphine is given. The nurse is caring for a patient with pneumonia. pain could be a sign of lung cancer, but there are
He follows all of the following except: also many other causes of pleuritic pain. A history
DIF: Cognitive Level: Application REF: 574 A) Positioning a client in a position so that the of COPD is often related to a history of smoking,
OBJ: Special Questions: Prioritization TOP: good lung is down but this is not stated in the answer. A productive,
Nursing Process: Implementation B) Gives the patient a high-humidity face mask purulent cough is most likely a sign of infection,
MSC: NCLEX: Physiological Integrity C) Making sure the reservoir bag on a non- possibly pneumonia
rebreather mask completely collapses when the
The nurse is caring for a patient with primary patient inhales A 95 year old Caucasian client is admitted with a
pulmonary hypertension who is receiving D) Report any signs of hypotension to the primary diagnosis of dehydration and changes in mental
epoprostenol (Flolan). Which assessment Answer: C. The reservoir bag on a non-rebreather status. IV fluids are flowing. His vitals are as
information requires the most immediate action? mask should NEVER completely collapse upon follows: 123/78, HR 84, RR 28, T 103 degrees,
a. The BP is 98/56 mm Hg. inhalation. Using the "good lung down" method SpO2 90%. He has a cough producing purulent
b. The oxygen saturation is 94%. allows for better oxygen perfusion, but no position sputum and pleuritic chest pain. The nurse
c. The patient's central intravenous line is should be used for extended periods of time. A suspects that he may have which of the following
disconnected. high-humidity face mask with oxygen allows for conditions?
d. The international normalized ratio (INR) is thinning secretions and keeps the respiratory A) Empyema
prolonged. system moist. Signs of hypotension should be B) Pneumonia
ANS: C reported as they may be an indication of shock, a C) PAH
The half-life of this drug is 6 minutes, so the nurse serious complication of pneumonia. D) FOD (Facebook Overload Disorder)
will need to restart the infusion as soon as Answer: B. Although Empyema often shares
possible to prevent rapid clinical deterioration. An elderly client with pneumonia may appear with many symptoms with pneumonia, there is not a
The other data also indicate a need for ongoing which symptoms first? productive cough with purulent sputum associated
monitoring or intervention, but the priority action is A) Altered mental status and dehydration with it. Chest pain can be a symptom associated
to reconnect the infusion. B) Fever and chills with PAH (pulmonary arterial hypertension) but
C) Hemoptysis and dyspnea none of the other symptoms listed are associated
DIF: Cognitive Level: Application REF: 581 D) Pleuritic chest pain and cough with it. 95 year olds are not normally avid
OBJ: Special Questions: Prioritization TOP: Answer: A. Often the first symptoms in elderly Facebook users, so this diagnosis would not be
Nursing Process: Assessment clients are altered mental status and dehydration likely.
MSC: NCLEX: Physiological Integrity
Which of the following is typically used to confirm Which of the following symptoms would be
A patient who was admitted the previous day with a diagnosis of lung cancer? associated with pulmonary edema? Select All that
pneumonia complains of a sharp pain "whenever I A) CT Scan Apply
take a deep breath." Which action will the nurse B) Bronchoscopy A) Air Hunger
take next? C) Surgical Biopsy B) Foamy, frothy sputum
a. Listen to the patient's lungs. D) V/Q Scan C) Anxiety
b. Administer the PRN morphine. Answer: C. Biopsy is the best confirmation of D) Bradycardia
c. Have the patient cough forcefully. cancer. A CT scan and bronchoscopy can be E) Crackles in lung bases that rapidly progress
d. Notify the patient's health care provider. used to visualize the area and check for any toward apices
ANS: A metastisis, but not to confirm the diagnosis. A V/Q Answer: A, B, C, and E. All of the following are
The patient's statement indicates that pleurisy or scan could be done, but is also not a confirmation signs of pulmonary edema. The client would most
a pleural effusion may have developed and the of a diagnosis. likely be experiencing tachycardia.
nurse will need to listen for a pleural friction rub
and/or decreased breath sounds. Assessment You are taking care of a patient who has just You are taking care of a patient who has been
should occur before administration of pain been diagnosed with having lung cancer. The diagnosed with pleurisy. The patient states "What
medications. The patient is unlikely to be able to patient says to you, "What could have caused this the **** is pleurisy! What kind of fool made up that
cough forcefully until pain medication has been to happen to me! I never smoked a day in my load of crap!?" Which of the following is the most
administered. The nurse will want to obtain more life!" Which of the following statements is best if appropriate response by the nurse?
assessment data before calling the health care made by the nurse. A) "You better watch your language, boy! I hope
provider. A) "Try to think about it, there was probably a time you don't kiss your mother with that mouth"
in your life where you must have smoked. That is B) "I'm sorry that you do not understand the
DIF: Cognitive Level: Application REF: 576 what causes this disease" diagnosis. I will call the doctor to have him answer
OBJ: Special Questions: Prioritization TOP: B) "It is possible for lung cancer to develop in a any questions you have"
Nursing Process: Assessment patient with a history of asthma or COPD" C) "This must be frustrating for you. Pleurisy is an
MSC: NCLEX: Physiological Integrity C) "Smoking is not the main cause of lung cancer. inflammatory disorder of the inner lining of the
Most likely you have cancer somewhere else in lungs, particularly the right lobe"
The nurse notes new onset confusion in an 89- your body that spread" D) "I understand you are frustrated. This disorder
year-old patient in a long-term care facility. The D) "There are some other causes besides is the inflammation of the layers of the outer part
patient is normally alert and oriented. In which smoking. Not eating enough fruits or vegetables of the lung. This condition developed due to your
order should the nurse take the following actions? or being exposed to environmental pollutants pneumonia.
could put you at risk"
Answer: D. Pleurisy (AKA Pleuritis) is a disorder considered cumbersome and not as accurate as a B) While you can reduce your risk some, you are
characterized by inflammation of both layers of Pulmonary Angiogram already at a major risk of developing this disease
the pleurae. It often develops in conjunction with because you are elderly
infections such as pneumonia, URI, or TB You are on the team taking care of the patient C) I see in your history a history of A-fib and
(although there are other causes as well). It is diagnosed with Pulmonary Embolism (PE). Which diabetes. Staying active, taking your
associated with both lobes, not just the right. The of the following activities takes priority? anticoagulant, and eating healthy can help reduce
nurse should be able to explain the diagnosis. A) Immediate Intubation your risk.
Answer A is not a professional, appropriate B) ABG/d-dimer D) In order to reduce your risk, you should move
response. C) Initiation of Heparin out of your long-term care facility and into your
D) Insertion of IV lines son or daughters house.
Which of the following would be considered a Answer: D. It is essential to get immediate access Answer: C. Having good nutrition, exercising, and
priority among the following nursing diagnoses for to IV (if not already established) in order to taking their anticoagulant therapy will help prevent
the client diagnosed with pleurisy (pleuritic)? establish route for medication and fluids, which is both pneumonia and stroke (which is a major
A) Acute Pain necessary to treat shock. ABG's should be drawn precipitator of developing pneumonia). While a
B) Risk for Injury before intubation in order to determine whether or pneumococcal vaccine can be given, it is not
C) Acute Fatigue not the patient must be intubated. Initiation of given annually. B is incorrect because it is
D) Imbalanced Nutrition Heparin is often done last after the diagnosis has nontherapeutic and offers no advice on how to
Answer: A. Pleurisy is characterized by sharp, been confirmed and other treatment options have reduce risk. While living in long-term care can
knife-like pain due to the inflamed pleural been explored. increase the risk of developing pneumonia, it is
membranes rubbing together. The pain itself can unreasonable to expect the patient to leave and
affect the breathing of the patient. All other Nurse Kim is taking care of a patient diagnosed move in with their children.
nursing diagnoses are not directly associated with with PE. She takes a set of vitals which are as
pleurisy, but could be influenced by the level of follows. BP 106/54, HR 97, RR 25, T 99.7, SpO2 You are taking care of a patient who has been
pain the client may be in. NSAID's, or in severe 90%. A Heparin bolus of 5000 units is being diagnosed with silicosis. You are teaching the
cases, narcotics or intercostal nerve blocks may administered via IV. The nurse notices a sore site patient about treatment options. Which of the
be used to treat pain. on the patient is starting to bleed. What is the following statements, if made by the nurse, is
priority action? correct?
The nursing instructor is explaining the difference A) Call the doctor A) There is no cure for this disease, but
between pleural effusion and empyema to the B) Stop the IV infusion sometimes chemotherapy can help improve
student. Which statement, if made by the student, C) Hold pressure at the site symptoms
indicates correct understanding? D) Initiate IV Fluids B) It is important that you have a PPD annually to
A) Pleural effusion is a collection of fluid in the Answer: C. The priority here is to apply pressure help detect for any signs of TB, which is a risk
base of the lungs, while empyema is collection of at the site of bleeding, then call the doctor. If after due to your condition
excess fluid in the membranes five minutes the direct pressure does not stop the C) Since you have already quit working with the
B) Pleural effusion is a collection of bleed, it is important to discontinue the infusion environmental hazard, there is nothing else we
serosanguinous fluid in the pleural space, but and notify the physician. It is not necessary to call can do to help with supportive care.
empyema is clear fluid a code. D) A bronchoscopy will be performed to
C) Pleural effusion is a collection of excess fluid in determine the best treatment option for you in
the interpleural space. Empyema is a type of The nurse is teaching the patient about ways to order to cure your condition.
pleural effusion with purulent fluid prevent atelectasis after surgery. Which Answer: B. It is important for those diagnosed
D) Pleural effusion must be treated with statement if made by the patient indicates the with silicosis to have a PPD done in order to
thoracentesis, while empyema is treated with need for further teaching? detect any signs of TB, as they are at risk for
pleurodesis A) "I will reposition myself at least every hour to developing it. There is no cure for this disease.
Answer: C. help my lungs breathe better" Chemotherapy is not used as a treatment option
B) "I will use my incentive spirometer by breathing unless cancer is detected. Other supportive
You are getting ready to hit that floor as a nurse! into the device to help my lungs expand" measures include O2 therapy, diuretics, and
You are pumped! Which of the following patients C) "Although I really don't want to, I will get out of bronchodilator therapy to help with activity
would be your priority?? bed this morning and walk over to my chair" intolerance.
A) The 84 year old male diagnosed with HAP D) "I will be given Mucomyst to help thin my lung
receiving vancomycin secretions"
B) The 27 year old patient with a DVT who Answer: B. An incentive spirometer should not be
complains of severe leg pain and a sudden cough blown into. Instead, the patient should inhale
C) The 56 year old female who arrived with an while holding the device in his/her mouth. This
acute asthma attack, but now has a respiratory should be performed 10 times every hour while
rate of 18 and SpO2 of 94% and has been in the awake. Repositioning and ambulation can help
hospital for three days properly expand lungs and help the body expel
D) The 25 year old patient with chest pain due to secretions. Mucomyst, although not always used,
a diagnosis of pleuritic can be used to loosen and thin secretions.
Answer: B. Severe leg pain and a sudden cough
are signs associated with a Pulmonary Embolism. A patient is has just undergone gastric bypass
This patient should be assessed immediately. The surgery and is postop day 1. The patient
patient with HAP (hospital acquired pneumonia) is complains of dyspnea, a bothersome and wet
receiving treatment and is not a priority. The cough, and has a temperature of 101 degrees.
patient with asthma would most likely be in need Which assessment data would indicate that this
of teaching as she is now stabilized. Chest pain is patient has pneumonia and not atelectasis?
important, but this patient already has a diagnosis A) Leukocytosis and sputum production
and comes second to the PE. B) Asymmetry of chest
C) Bronchial lung sounds in bases
Which of the following diagnostic tools is the most D) X-ray is the only definitive way
accurate when confirming a diagnosis of PE? Answer: D. Most of the signs and symptoms of
A) X-ray atelectasis and pneumonia are extremely similar,
B) CT scan with contrast although not all symptoms are found in every
C) V/Q scan case of atelectasis or pneumonia. The best way
D) Pulmonary Angiogram to truly determine the difference is to obtain a CT
Answer: D. Pulmonary angiogram allows for or X-ray of the area.
visualization of pulmonary vasculature under
fluoroscopy and is considered the best diagnostic A 72 year old patient asks you, "What can I do to
tool for this incident. X-Ray is often used to rule reduce my chance of getting pneumonia?" What
out any other causes such as COPD or is the best response by the nurse?
pneumonia. CT scan can be used to diagnose a A) It is important for you to get your
PE, but it is less sensitive than a Pulmonary pneumococcal vaccine every year which will help
Angiogram. V/Q scans, while still often used, is protect you from pneumonia