Answers and Explanations

Chapter Quiz

The Answer is 3
The nurse is assessing an irritable 6-month-old infant during a well-baby checkup. The infant’s weight is 19 lb., 6.4 oz. (8.8 kg). The infant does not have an elevated temperature, the heart rate is 102, and the respiratory rate is 32. The mother states that the infant wakes every hour or two throughout the night. The infant wants a bottle, and falls asleep while eating, but doesn’t stay asleep. Which of the following instructions should the nurse give the parents?

Category: Rest and sleep
1. Tylenol may be appropriate for teething pain, and Benadryl is an antihistamine that may cause drowsiness, but the doses as given are for adults.
2. The infant’s weight is within normal limits, so high-calorie foods may not be appropriate.
3. CORRECT: The infant is having sleep disturbances related to nighttime feeding. Feeding late and putting the infant to bed awake help the infant learn to recognize bedtime and to self-soothe to fall asleep.
4. The Academy of Pediatrics does not promote putting infants to bed with parents. Rocking the infant will not help learning to self-soothe.
The Answer is 2
The nurse caring for a child burned over 20% of her body assists the physician in performing dressing changes on day 5 after the initial injury. The child appears disoriented, has a fever of 101º F (38.3º C), and is crying in pain. Which of the following nursing interventions would be the MOST appropriate in caring for this client?

Category: Non-pharmacological comfort interventions
1. The nurse would gather equipment, but not before addressing the crying child.
2. CORRECT: The child may be suffering from an infection. The nurse recognizes that disorientation and fever are the first signs of sepsis in burn clients. It would be most appropriate to assess for the causes of fever and pain and notify the physician before proceeding.
3. Analgesics may be appropriate but not before assessing the pain and source of fever and disorientation.
4. Distractions may be offered after the assessment but they do not take priority over notifying the physician regarding the findings about the source of fever and pain.
The Answer is 2
The nurse is taking care of a young child a few hours after a tonsillectomy. Which of the following nursing interventions would be appropriate to promote adequate nutrition and oral hydration for this child?

Category: Nutrition and oral hydration
1. Warm liquids may increase bleeding and should be avoided the first few hours after surgery.
2. CORRECT: The child may first take ice chips 1–2 hours after awakening, followed by cool, clear liquids without pulp or ice pops. Gentle suctioning may be necessary to remove secretions in the mouth and to keep the child from gagging. Suctioning should be kept to a minimum to avoid traumatizing the oropharynx.
3. The physician may maintain an intravenous infusion postoperatively, but it is not necessary to keep the child NPO after the surgery. Ice chips or cool, clear liquids are soothing.
4. Soft foods are not given in the first few hours after surgery to prevent emesis. Orange juice is acidic, and juices should be alkaline when offered to a postoperative child. Milk products are controversial because they coat the throat and may cause the child to cough.
The Answer is 4
The nurse is caring for a child who had an adenoidectomy and tonsillectomy 10 hours ago. The parents are in the room and preparing the child for bedtime. Which of the following nursing interventions would be helpful to promote rest and sleep for this client?

Category: Rest and sleep
1. Semi-Fowler’s may not be a position comfortable for some children, so other positions may need to be considered.
2. The parents should be encouraged to stay with the child and to participate in the care and comfort of the child, if possible.
3. Suctioning should not be vigorous after an adenoidectomy or a tonsillectomy.
4. CORRECT: Assist the child in finding a position of comfort. This may be prone, semi-prone, or semi-Fowler’s. An ice collar and a cool oral rinse will also aid in comfort.
The Answer is 4
The nurse has been assigned to an adult male client who is less than 24 hours post-op. In report, the nurse learns that he rings his call light frequently, is anxious, and has had pain medication as ordered. Which of the following nondrug nursing interventions should the nurse include when caring for this client?

Category: Non-pharmacological comfort interventions
1. The client will probably be more reassured if physical comfort measures are taken, rather than just verbal assurances.
2. Prioritizing is necessary, but avoiding an already anxious client may cause the nurse to overlook a serious symptom.
3. Call a physician, if needed, AFTER offering basic comfort measures and doing an assessment.
4. CORRECT: Changing the client’s position, removing wrinkles in the bed linen, helping the client to take a drink, or limiting noise can help the client to rest and may reduce pain.
The Answer is 1
The nurse is taking care of an adult male with bilateral leg fractures. He has a long leg cast on his right leg as well as traction applied to the left femur. Which of the following is the MAIN purpose served by the cast for this client?

Category: Mobility/immobility
1. CORRECT: A long leg cast serves to immobilize the tibia and fibula by being placed above and below the knee and ankle joints.
2. A long leg cast is not used for comfort for a client in traction.
3. A long leg cast does not immobilize the pelvis.
4. A body cast, not a long leg cast, encircles the trunk.
The Answer is 4
The nurse is taking care of an elderly male client who has shortness of breath, cough, and fluid in his pleural space. The physician asks the nurse to assist in the performance of a therapeutic and diagnostic thoracentesis. Which of the following nursing interventions should the nurse perform to assist this client?

Category: Non-pharmacological comfort interventions
1. The nurse should make certain that consents are signed before the start of a procedure, but that does not affect the client’s comfort.
2. Fluids should not be offered right before a procedure to avoid nausea and vomiting if pain is experienced.
3. Lying flat with feet elevated is not the position of choice for a thoracentesis.
4. CORRECT: Placing the client in a sitting position over a bedside table is the most comfortable and allows the best opportunity to remove fluid at the base of the chest.
The Answer is 2
The nurse has been assigned to a 2-day-old male infant on the mother/baby unit of an acute care facility. The infant will undergo a circumcision procedure in the afternoon, before being discharged the following morning. Which of the following non-pharmacologic interventions should the nurse teach the parents to keep this infant comfortable while the circumcision heals?

Category: Non-pharmacological comfort interventions
1. Leaving the diaper slightly loose when fastening will be more comfortable.
2. CORRECT: Petroleum jelly offers lubrication and helps stop the friction of the diaper over the raw area.
3. Offering feedings more often than necessary may cause emesis and is not the best way to soothe an infant.
4. The end of the penis has a yellow exudate that is part of the healing process and should not be vigorously washed off. It will disappear with healing.
The Answer is 4
The nurse is taking care of a quadriplegic young man who suffers from a C2-C3 fracture after an auto accident 3 months prior. He has a tracheotomy, is ventilator-dependent, and has been discharged to home with skilled home nursing care. The nurse knows that this client is at risk for autonomic dysreflexia. Which of the following measures should this nurse take to keep the client comfortable, manage his elimination needs, and prevent common causes of autonomic dysreflexia?

Category: Elimination
1. Turning is necessary to prevent decubitus ulcers and promote comfort, but it does not necessarily prevent an increase in blood pressure as seen with autonomic dysreflexia.
2. Sleeping 8–10 hours is not related to autonomic dysreflexia.
3. Offering fluids is a nursing measure but may not be related to autonomic dysreflexia because a client with a spinal cord injury may have a fluid restriction to help control blood pressure.
4. CORRECT: Bladder distension and bowel impaction can result in autonomic dysreflexia, causing a critical increase in blood pressure.
The Answer is 3
The nurse is taking care of a child after an open reduction of the radius and ulna of her right arm. The child is now immobilized in a plaster cast splint reinforced with an Ace wrap. Which of the following non-pharmacological nursing interventions will promote comfort for this child?

Category: Non-pharmacological comfort interventions; Mobility/immobility
1. Heat would not be appropriate, because it could cause, rather than reduce, swelling.
2. The cast should be elevated for the first 24–48 hours and not be left flat on the mattress.
3. CORRECT: Elevating the extremity and applying an ice pack will help to reduce swelling and may reduce pain. Repositioning is a comfort intervention.
4. The child should not be totally immobile because it can lead to post-op respiratory complications.
The Answer is 1 and 2
The nurse is taking care of an elderly client with left-sided heart failure. Which of the following are the MOST appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.

Category: Rest and sleep
1. CORRECT: Taking short walks may provide distraction and increase mobility, circulation, and overall well-being if tolerated.
2. CORRECT: Allowing the client to sit in an armchair makes it easier to breathe and is a safe alternative to an armless chair. It is also helpful to have the client raise the head of the bed when sleeping or napping. These are appropriate for a client with left-sided heart failure.
3. A client in left-sided heart failure most likely will not tolerate lying flat, so this would not promote sleep and rest in this position.
4. A bedside commode would reduce the work of getting to the bathroom and should be used.
The Answer is 2
The nurse is instructing a male client on the proper use of crutches for an ankle injury. He will be required to be non-weight bearing for 4–6 weeks. Which of the following crutch gaits should the nurse teach this client for safe ambulation?

Category: Assistive devices
1. The two-point gait is an advanced four-point gait and allows for faster ambulation with minimal support.
2. CORRECT: The three-point gait is the safest to use when one leg is injured. Both crutches and the injured leg move forward, followed by swinging the stronger lower extremity as the rest of the body weight is placed on the crutches.
3. The four-point gait is used as a slow and stable gait for those who can bear weight on each leg.
4. Gait training is part of client education when crutches or adaptive equipment is used for ambulation.
The Answer is 4, 3, 2, 1
The nurse is working in an extended care facility when a nursing assistive personnel (NAP) reports that an elderly client is crying in pain. The nurse finds the client in the bathroom reporting severe constipation. What would be the appropriate order of nursing interventions to assist this client with his immediate elimination needs? All options must be used.

Category: Elimination
1. This is last in the appropriate order of nursing interventions. Oral fluids should be increased but will not impact the immediate pain and constipation.
2. Relief of the immediate pain is the priority. After an attempt to manually remove the impaction, and offering a PRN medication, the physician should be notified.
3. PRN medications do not offer immediate relief and may not be effective if the impaction is solid. After a manual exam assessment, and an attempt to remove the stool, it would be appropriate to offer a PRN medication orally, if ordered, to prevent a repeat incident.
4. The first nursing intervention should be manual assessment and removal of the fecal impaction. This will offer immediate relief while helping to assess what needs to be relayed to the physician.
The Answer is 1
The nurse is caring for a young child who has recently had a vesicostomy. Which of the following nursing interventions should the nurse undertake to assist this child with basic comfort and elimination?

Category: Elimination
1. CORRECT: A vesicostomy is performed when chronic neurogenic bladder and frequent urinary tract infections become problematic. Hydration, cleansing and drying of the area, absorbent diapers, and daily dilation of the opening are all appropriate care to prevent infection and to provide comfort.
2. Double diapers alone are not enough to keep the child comfortable and free from infection.
3. It is not customary to apply a urine bag over the opening of a vesicostomy.
4. The addition of a urine bag to double diapers will not keep the child comfortable and free from infection.
The Answer is 1
A client who has chronic pain asks the nurse about alternative therapy in conjunction with traditional treatment. Which of the following forms of alternative therapy could the nurse provide for this client?

Category: Alternative therapy; Non-pharmacological comfort interventions
1. CORRECT: Music therapy and guided imagery have been proven to increase a client’s ability to perform activities of daily living by helping to focus on something other than pain.
2. Acupuncture must be performed by a skilled practitioner and is not done by a nurse.
3. Kegel exercises are done independently by the client to tighten the muscles of the pelvic floor. They do not provide pain relief.
4. Nurses may participate in many forms of alternative therapies as nursing interventions when trained properly.
The Answer is 2
The nurse is taking care of an adult client with a fractured femur who must be maintained in traction for several days before surgical interventions can take place. The client has several abrasions, his hair is dirty, and he has healing wounds in his mouth. Which of the following nursing interventions should the nurse use in caring for the personal hygiene of this client?

Category: Personal hygiene
1. The client may be able to do some of his bath, but it would not be possible for him to cleanse his own back and other areas while maintaining traction.
2. CORRECT: Assisting with the bath allows inspection of the skin for any pressure areas; gentle teeth brushing and hair cleansing are nursing measures and promote comfort while maintaining the traction.
3. A family member should not be responsible for inspecting the skin and maintaining the traction. These are nursing responsibilities.
4. Oral care is important but the bath should not be postponed and can easily be done with the client in traction. It will promote comfort and healing.
The Answer is 2
The nurse is taking care of an adult client with a long-bone fracture. The nurse encourages the client to move fingers and toes hourly, to change positions slightly every hour, and to eat high-iron foods as part of a balanced diet. Which of the following foods or beverages should the nurse advise the client to avoid while on bed rest?

Category: Nutrition and oral hydration; Mobility/immobility
1. Fruit juices can be taken while on bed rest.
2. CORRECT: Too much milk increases the demand on the kidneys to excrete calcium and can lead to kidney stones.
3. Cranberry juice can be taken while on bed rest and also aids in prevention of urinary tract infections.
4. Some foods should be avoided or limited while on bed rest. For instance, milk and milk products should be avoided or limited while on bed rest to avoid kidney stone formation.
The Answer is 3
The nurse working in an outpatient clinic has the opportunity to teach an insulin-dependent client. Which of the following topics would be MOST appropriate for the nurse to include when teaching personal hygiene?

Category: Personal hygiene
1. Oral care is an important part of diabetic hygiene to prevent cavities and infections.
2. Hair care is not the most important part of personal hygiene, although it is important for self-esteem.
3. CORRECT: Skin care is essential to prevent infection and skin breakdown. This is especially true for the feet, where a client may not see or feel problem areas.
4. Personal hygiene is definitely a part of self-care teaching for an insulin-dependent client.
The Answer is 1
The nurse is taking care of a child in the ambulatory care clinic. The parents relate a 24-hour period of gastrointestinal distress, including vomiting several times and 3 watery stools. Which of the following should the nurse do to assist in maintaining nutrition for this child?

Category: Nutrition and oral hydration
1. CORRECT: Signs of dehydration would be part of parental teaching, and a slow introduction of clear liquids advancing to other liquids is appropriate.
2. It would not be appropriate for the nurse to suggest that the parents offer whatever foods the child feels like taking, without first educating the parents about the signs of dehydration.
3. Milk products would not be the first type of fluids offered for a child who has been vomiting, due to how irritating milk can be on the digestive system.
4. Solid foods are introduced later, after liquids are offered over several hours, once vomiting has stopped.
The Answer is 3.1 mL/hour

An 11-lb. (5-kg) infant is NPO after a minor surgical procedure. What would be the appropriate rate of infusion of intravenous fluids if the physician ordered fluids to run at 15 mL/kg/day? Record your answer using one decimal place.

Category: Nutrition and oral hydration

Multiply 5 kg by 15 mL/kg. This equals 75 mL. Then divide 75 mL by 24 hours in a day to arrive at the answer: 3.1 mL/hr. The nurse would run the IV at 3.1 mL/hr over 24 hours to get the ordered amount of fluid.

mL/hr
The Answer is 4
An adult diagnosed with pancreatic cancer is having a consultation with the nurse about nutrition and hydration. Which of the following suggestions might the nurse include when providing education to this client?

Category: Nutrition and oral hydration
1. It is more appropriate to progress the diet slowly to avoid nausea and vomiting.
2. Pureed foods may cause nausea and gagging, low-protein foods do not offer enough nutrients, and daily weights are the norm.
3. Herbal therapies have not been researched enough to be certain that they would not interfere or compromise cancer treatments when ingested. Topical herbal treatments may be of use for comfort.
4. CORRECT: Flavored foods high in both protein and carbohydrates will help to increase calorie intake. Foods that have less odor, and small, frequent meals help ward off nausea.
The Answer is 2
The nurse is caring for an elderly client who has been on long-term nutritional support. The nurse is reviewing the infusion procedure with the client’s daughter. The nurse states which of the following as the rationale for removing the formula from the refrigerator and infusing it through the gastrostomy tube at room temperature?

Category: Nutrition and oral hydration
1. There would not be a taste to formula given through the G-tube.
2. CORRECT: Cold formula through the G-tube can cause discomfort and cramping.
3. It is most appropriate for the comfort of the client to bring the formula to room temperature before administering.
4. Temperature has nothing to do with the risk of aspiration.
The Answer is 3
The nurse is working with a middle-aged female after a knee injury. Ambulation is still difficult for the client, and the physical therapist has suggested the client use a cane. The nurse states which of the following with respect to using a cane rather than a walker for this injury?

Category: Assistive devices
1. A cane is not used as a reminder for good posture; it is used for comfort and support.
2. A cane is safe when used properly.
3. CORRECT: A cane offers support and can give the client relief of joint pain and fatigue, and promote a safe way to ambulate when a lower extremity is injured.
4. A cane does offer relief on weight-bearing joints when used properly.
The Answer is 1 (E), 2 (D), 3 (B), 4 (C), 5 (A)
The nurse is preparing for a pediatric trauma admission in which traction will be applied to immobilize a femur fracture for a child. The nurse reviews the forms of traction and the purposes for each before gathering equipment prior to the child’s arrival. Match the type of traction on the left with the type of injury or indication on the right. All options must be used.

Category: Mobility/immobility
1. (E): Bryant’s traction is used in children younger than age 2 to reduce femur fractures or stabilize hips.
2. (D): Russell’s traction may reduce fractures of the hip or femur.
3. (B): 90-degree traction is used on the femur if skin traction isn’t suitable.
4. (C): Buck’s traction is used to temporarily immobilize a fractured leg.
5. (A): Cervical traction is used to stabilize a spinal fracture or muscle spasm.
The Answer is 3
It is important to evaluate pain in the neonate. Look at the chart below. What would the pain score be for an infant with a high-pitched cry, O₂ saturation of 96%, a grimace, and frequent periods of wakefulness?

Score

0 1 2

Crying No High-pitched Inconsolable

Requires O₂ No < 30% > 30%

Expression None Grimace Grimace/grunt

Sleepless No Wakes frequently Always awake

Category: Rest and sleep
1. A score of 0 is incorrect, because the infant has a grimace (1), periods of wakefulness (1), and a high-pitched cry (1).
2. A score of 2 is incorrect, because the infant has a grimace (1), periods of wakefulness (1), and a high-pitched cry (1).
3. CORRECT: A pain score of 3 is the closest evaluation with the information given. The infant has a high-pitched cry (1), an adequate O₂ saturation (0), a grimace (1), and periods of wakefulness (1).
4. Enough information is provided to answer the question.

Score
	0	1	2
Crying	No	High-pitched	Inconsolable
Requires O₂	No	< 30%	> 30%
Expression	None	Grimace	Grimace/grunt
Sleepless	No	Wakes frequently	Always awake