Comp 3

Which client statement indicates the need for additional teaching about benzodiazepines? "I cannot drink alcohol while taking diazepam." "I can stop taking the drug anytime I want." "Diazepam can make me drowsy, so I should not drive for a while." "Diazepam will help my tight muscles feel better."

"I can stop taking the drug anytime I want." Explanation: Diazepam, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly tapered off of the medication to decrease withdrawal symptoms, which would be similar to withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased central nervous system depressant effect and therefore should be avoided. Diazepam can cause drowsiness, and the client should be warned about driving until tolerance develops. Diazepam has muscle relaxant properties and will help tight, tense muscles feel better.

The nurse has instructed the client about the correct positioning of the leg and hip following hip replacement surgery. Which statement indicates that the client has understood these instructions? "I may cross my legs as long as I keep my knees extended." "I should avoid bending over to tie my shoes." "I can sit in any chair that I find comfortable." "I should avoid any unnecessary walking for about 3 months after my surgery."

"I should avoid bending over to tie my shoes." Explanation: Acute flexion and adduction of the hip should be avoided after hip replacement surgery and the client should not bend over to tie the shoes. Slip on shoes that can be positioned with a long handled shoe horn are preferred. The client may not cross (adduct) the legs as this is a risk for dislocating the prosthesis. The client should not sit in low chairs that will require excessive hip flexion to get in or out of. Hip flexion also increases the risk of dislocation. Frequent walks are encouraged to increase muscle strength and provide hip exercises.

A 12-year-old child sustains a moderate burn injury. The mother reports that the child last received a tetanus injection when he was five years old. Which immunization would the nurse anticipate an for this child? 0.5 ml of tetanus toxoid IM 0.5 ml of tetanus toxoid IV 250 units of tetanus immune globulin IM 250 units of tetanus immune globulin IV

0.5 ml of tetanus toxoid IM Explanation: Tetanus prophylaxis is given to all clients with moderate to severe burn injuries if it has been longer than five years since the last immunization, or if there is no history of immunization. The correct dosage is 0.5 ml IM, one time, if the child was immunized within 10 years. If it has been more than 10 years, or the child hasn't received tetanus immunization, the dosage is 250 units of tetanus immune globulin, one time. There is no IV form of tetanus immune globulin available.

For the client receiving outpatient treatment for depression and suicidal ideation, what is the correct amount of imipramine to have at one time? a 30-day supply a 21-day supply a 14-day supply a 7-day supply

7-day supply explanation: Because the client has a history of recurring depression and suicidal ideation, the nurse would give the client a 7-day supply of imipramine to prevent possible overdose. Giving the client a 14-, 21-, or 30-day supply of medication would provide the client with enough medication to complete a suicide attempt. Tricyclic antidepressants are associated with a higher rate of death than are selective serotonin reuptake inhibitors.

A nurse is assigned four clients. Which client should the nurse see first? A 17-year-old client 24 hours post appendectomy A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome A 50-year-old client three days post myocardial infarction A 50-year-old client with diverticulitis

A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome explanation: Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation seen first. There is no information to suggest that the client with post myocardial infarction has an arrhythmia or other complication. There is no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

A 60-year-old black man Explanation: Multiple myeloma is more common in middle-aged and older clients. The median age at diagnosis is 60 years. It is twice as common in blacks as it is in whites. It occurs most often in black men.

A client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, what should the nurse tell the client? A bathroom can be shared with an adult who is not pregnant. Urinary and bowel excretions are not considered contaminated. Disposable plates and plastic utensils must be used during the entire course of chemotherapy. Any contaminated linens should be washed separately and then washed a second time, if necessary.

Any contaminated linens should be washed separately and then washed a second time, if necessary. explanation: The client may excrete the chemotherapeutic agent for 48 hours or more after administration. Blood, emesis, and excretions may be considered contaminated during this time, and the client should not share a bathroom with children or pregnant women. Any contaminated linens or clothing should be washed separately and then washed a second time, if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste.

After 10 days of lithium therapy, the client's lithium level is 1.0. How does the nurse interpret this value? a laboratory error. an anticipated therapeutic blood level of the drug an atypical client response to the drug a toxic level

An anticipated therapeutic blood level to the drug Explanation: The therapeutic blood level range for lithium is between 0.6 and 1.2 for adults. A level of 1.0 can be anticipated after 10 days of treatment. Lithium toxicity occurs at levels above 1.5. While laboratory error can occur, that possibility would be more plausible if the level were extremely high or low. An atypical response would be manifested as an unusual physical or psychological response, not through blood levels.

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? Hypertension Uterine infection Placenta previa Severe pain

Placenta previa Explanation: The client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the lower uterine segment doesn't contract as well as the fundal part of the uterus; therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don't increase the client's risk for postpartum hemorrhage.

A client with Paget's disease comes to the hospital and complains of difficulty urinating. The emergency department physician consults urology. What should the nurse suspect is the most likely cause of the client's urination problem? Renal calculi Urinary tract infection (UTI) Benign prostatic hyperplasia Dehydration

Renal calculi Explanation: Renal calculi commonly occur with Paget's disease, causing pain and difficulty when urinating. A UTI commonly causes fever, urgency, burning, and hesitation with urination. Benign prostatic hyperplasia is common in men older than age 50; however, because the client has Paget's disease, the nurse should suspect renal calculi, not benign prostatic hyperplasia. Dehydration causes a decrease in urine production, not a problem with urination.

A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next? Perform a vaginal examination. Notify the health care provider (HCP) of the decelerations. Reposition the client and continue to evaluate the tracing. Administer oxygen via mask at 2 L/min.

Reposition the client and continue to evaluate the tracing. Explanation: The cause of variable decelerations is cord compression, which may be relieved by moving the client to one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the decelerations are not relieved by position changes, oxygen should be initiated, but the rate should be 8 to 10 L/min. Notifying the HCP should occur if turning the client and administering oxygen does not relieve the decelerations. (find this in notes)

ROP position:

Right occiput posterior- baby is head down and back is to the side- the right side.

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care? The client doesn't want to discuss death around his girlfriend. The client entered a clinical trial through the National Cancer Institute. The physician orders weekly blood transfusions to be given at home. The client explains that he isn't ready to complete his will.

The client entered a clinical trial through the National Cancer Institute. Explanation: The client involved in a clinical trial needs additional teaching about hospice care. This treatment option suggests that the client isn't ready for palliative care, which is a criterion for hospice care. Preferring not to discuss death around the girlfriend and not feeling ready to complete a will are normal responses to the grieving process. Blood transfusions are considered palliative care.

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which of the following interventions is the nursing priority? Have the client contact the family to come down to visit. Ask what the fears are and why the client is becoming agitated. Check on the client frequently to see the adjustment. Explain procedures and unit routines to the client, as well as checking orientation.

Explain procedures and unit routines to the client, as well as checking orientation. Explanation: Explaining procedures and routines decreases the client's anxiety about the unknown. This is especially important to an elderly client who has been transferred from a familiar environment to a new one. Checking orientation gives feedback as to how the client is coping with the changes. Since there is fear and anxiety, it would be a challenge for the client to contact the family. "Why" questions tend to be judgmental and do not address the main concerns. Checking on the client is not sufficient; explanations will help ease the anxiety.

The student nurse is admitting an elderly patient admitted with congestive heart failure and sets up the room with standard precautions. Which of the following is noted by the nursing instructor as the best action? Wearing gloves for all client contact. Considering all body substances potentially infectious. Placing a body substance isolation sign on the client's door. Wearing a gown if the client is in respiratory isolation.

Considering all body substances potentially infectious Explanation: Standard precautions are based on the concept that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are inappropriate when caring for a client in respiratory isolation because they don't prevent transmission of airborne respiratory infections. The nurse should wear a mask as a barrier to such infections.

The nurse prepares the client for a lumbar puncture (LP) (see client chart below) to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure? 2/10/2017 1900 56-year-old, right-handed female presents with severe onset of headache and projectile vomiting that started 45 minutes prior to admission. Physical examination findings include nuchal rigidity. Severe vomiting Suspected increased intracranial pressure (ICP) Client requires mechanical ventilation Blood in the cerebrospinal fluid (CSF)

Suspected increased intracranial pressure (ICP) explanation: Sudden removal of CSF result in a lowered pressure in the lumbar area than in the brain which can cause brain herniation, especially in the presence of increased ICP. Therefore a LP is contraindicated when increased ICP is suspected. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. A LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage.

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage? Cranberry juice Coffee Prune juice Milk

Milk Explanation: A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.

The nurse is caring for a child with acute glomerulonephritis. What action is most important for the nurse to do? Obtain and monitor daily weight Increase oral fluid intake Provide sodium supplements Monitoring the client for signs of hypokalemia

Obtain and monitor daily weights explanation: The child with acute glomerulonephritis should be monitored for fluid imbalance, which is done through daily weights. Increasing oral intake and providing sodium supplements aren't part of the therapeutic management of acute glomerulonephritis. Impaired renal function is associated with increased, not decreased, potassium levels.

A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea? Begin clear fluids. Withhold food and fluids for 2 hours. Offer yogurt several times a day. Restrict the intake of pizza.

Offer yogurt several times a day explanation: Diarrhea is a common adverse effect of amoxicillin because the drug kills normal intestinal bacteria. Yogurt with live cultures helps restore the normal intestinal flora. Restricting the child to clear fluids will not help stop the diarrhea or recolonize the intestine. Withholding food and fluids for 2 hours is suggested when a child vomits. Pizza tends to be spicy and aggravates the diarrhea, but restricting its intake will not help the underlying problem.

In a client infected with human immunodeficiency virus (HIV) has a low CD4 level. What interventions should the nurse implement as a result of this finding? Increase nutritional protein with each meal. Request human granulocyte colony-stimulating factor to improve WBC production. Place the client in reverse isolation. Provide antibiotics as per order.

Place the client in reverse isolation Explanation: CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection, but does not identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests. Because of the client's risk, isolation is recommended.

ischemic stroke:

(clot) thrombotic- clot in brain embolic- clot somewhere other than brain

TCAs

Amitriptyline. Amoxapine. Desipramine (Norpramin) Doxepin. Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil)

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus?

Droplet precautions

Types of strokes:

Ischemic, hemorrhagic, transient ischemic attacks (TIAs)

anticholinergic drugs:

Oxybutynin (Ditropan, Gelnique), tolterodine (Detrol), Darifenacin (Enablex), Solifenacin (Vesicare), Trospium (Sanctura), Fesoterodine (Toviaz)

Paget's disease

a bone disease of unknown cause characterized by the excessive breakdown of bone tissue, followed by abnormal bone formation

Laennec's Cirrhosis

a type of cirrhosis of the liver characterized by a nodular appearance of the liver surface, associated with alcoholism.

Guillain-Barre syndrome

autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response, and sudden muscle weakness

While caring for a pregnant adolescent, a nurse should develop a care plan that incorporates the adolescent's:

level of emotional maturity

Thoracentesis

surgical puncture to remove fluid from the pleural space

MAOIs (monoamine oxidase inhibitors)

rasagiline (Azilect), selegiline (Eldepryl, Zelapar), isocarboxazid (Marplan), phenelzine (Nardil), and. tranylcypromine (Parnate).

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which would most likely contribute to the achievement of this goal? implementing relaxation exercises administering a sedative as needed providing a soft, bland diet administering famotidine as ordered

administering famotidine as ordered explanation: Clients with burns are susceptible to the development of Curling's ulcer, a gastroduodenal ulcer that is caused by a generalized stress response. The stress response results in increased gastric acid secretion and a decreased production of mucus. Prevention is the best treatment, and clients are frequently treated prophylactically with antacids and H2 histamine blockers such as famotidine.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

airborne and contact precautions explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

Clindamycin

antibiotic

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform which exercise? tailor sitting leg lifting shoulder circling squatting

tailor sitting Explanation: Tailor sitting, also referred to as cobbler's or butterfly pose, is an excellent exercise that helps to strengthen the client's back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. Leg lifts are helpful for leg aches. Shoulder circling exercises are helpful for neck and upper backaches. Squatting is not helpful for alleviating lower backaches.

The client is in the oliguric phase of acute renal failure. For which risk should the nurse assess the client? pulmonary edema metabolic alkalosis hypotension hypokalemia

pulmonary edema explanation: Pulmonary edema can develop during the oliguric phase of acute renal failure because of decreased urine output and fluid retention. Metabolic acidosis develops because the kidneys cannot excrete hydrogen ions, and bicarbonate is used to buffer the hydrogen. Hypertension may develop as a result of fluid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? cholesterol level pupil size and pupillary response bowel sounds echocardiogram

pupil size and pupillary response explanation: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.

Which is the highest priority action by the nurse before completing this skill? Place client in the supine position. Assess stomach residual. Flush tube with 100 cc of water. Assess bowel sounds.

assess stomach residual explanation: The picture provided is of a nurse administering a bolus tube feeding. Prior to administration, the highest priority would be to assess tube patency and stomach residual. Both can be accomplished by checking stomach residual. The client is placed in a Fowler's position for feeding, not supine. It is common to flush the tube after patency and residual are assessed. Bowel sounds are assessed as part of a routine assessment.

Which should the nurse closely assess in a client who is reversing from general anesthesia and receiving clindamycin? tachycardia respiratory depression hypotension renal failure

respiratory depression Explanation: The client who has received general anesthesia with neuromuscular blocking agents must be carefully monitored when given clindamycin. A serious interaction could be enhanced, neuromuscular blockage, skeletal muscle weakness, or respiratory depression, if this combination is used during or immediately after surgery. Concurrent use should be avoided. The combined effect of the medications places the client at increased risk, and the nurse should assess the client closely for respiratory depression or paralysis. The nurse will be monitoring the client's heart rate, blood pressure, and urinary output but not specifically because of potential drug interactions and adverse effects of clindamycin.

Which food should the nurse tell the client to avoid while taking phenelzine? roasted chicken salami fresh fish hamburger

salami Explanation: Phenelzine is a monoamine oxidase inhibitor (MAOI). MAOIs block the enzyme monoamine oxidase, which is involved in the decomposition and inactivation of norepinephrine, serotonin, dopamine, and tyramine (a precursor to the previously stated neurotransmitters). Foods high in tyramine—those that are fermented, pickled, aged, or smoked—must be avoided because, when they are ingested in combination with MAOIs, a hypertensive crisis occurs. Some examples include salami, bologna, dried fish, sour cream, yogurt, aged cheese, bananas, pickled herring, caffeinated beverages, chocolate, licorice, beer, red wine, and alcohol-free beer.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction?

dystonia explanation: Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements, particularly around the mouth. Fluphenazine- typical antipsychotic

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that: the client requires an antiviral agent. enteric precautions must be continued. enteric precautions can be discontinued. the client's infection may be caused by droplet transmission.

enteric precautions must be continued. explanation: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate? helping the client to evaluate her sister's behavior telling the client to avoid details of the accident facilitating progressive review of the accident and its consequences postponing discussion of the accident until the client brings it up

facilitating progressive review of the accident and its consequences Explanation: The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process. Helping the client to evaluate her sister's behavior, telling the client to avoid details of the accident, or postponing the discussion of the accident until the client brings it up is not therapeutic and does not facilitate the development of trust in the nurse. Such actions do not facilitate review of the accident, which is necessary to help the client integrate feelings and memories and begin the grieving process.

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief? lithotomy right lateral hands and knees tailor sitting

hands and knees explanation: Placing the client in the hands and knees position pulls the fetal head away from the sacral promontory (relieving pain) and facilitates rotation of the fetus to the anterior position. Lithotomy is the position preferred by some health care providers (HCP) for delivery but does not facilitate rotation. The right lateral position will perpetuate the ROP position. Tailor sitting facilitates descent in OA positions.

A client tells the nurse, "Everybody smiles at me because they know that I was chosen by God for this mission." The nurse interprets this statement as which finding? idea of reference thought insertion visual hallucination neologism

idea of reference explanation: An idea of reference is a person's view that other people recognize that she has an important characteristic or power. Thought insertion refers to a person's belief that others, or a specific other, can put thoughts into her mind. Visual hallucinations involve seeing objects or persons not based on reality. A neologism is a word or phrase that has meaning only to the person using it.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of: sterile water. glucose water. standard infant formula. iron-fortified infant formula.

iron-fortified infant formula explanation: For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is appropriate for the neonate. is too large because it covers the neonate's eyes. is too small because it obstructs the nose. should be covered with a soft cloth before being placed against the skin.

is appropriate for the neonate explanation: The correct size covers the nose but not the eyes. The mask is too large if it covers the neonate's eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin.

A physician orders lithium carbonate for a client who has just been diagnosed with bipolar disorder. The nurse is teaching the client about signs and symptoms of lithium toxicity, which include: skeletal muscle contractions, cogwheel rigidity, and a thick tongue. dry mouth, blurred vision, and urine retention. edema, orthostatic hypotension, and rash. lethargy, vomiting, and diarrhea.

lethargy, vomiting, and diarrhea. explanation: Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop. Lithium doesn't cause extrapyramidal effects, such as skeletal muscle contractions, cogwheel rigidity, and a thick tongue, or cholinergic effects, such as dry mouth, blurred vision, and urine retention. The drug also doesn't cause edema, orthostatic hypotension, or rash.

A registered nurse on the neonatal unit appropriately uses the chain of command when she: discusses unprofessional behavior of laboratory personnel with the laboratory manager. asks the unit manager to grant her vacation requests. notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. e-mails the housekeeping supervisor about a problem on the nursing unit.

notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. explanation: The concept of chain of command requires that the nurse contact the nurse-manager for issues related to other departments; the nurse-manager should handle such issues. Contacting the laboratory manager, asking the unit manager to grant her vacation requests, and e-mailing the housekeeping supervisor aren't appropriate uses of the chain of command.

hemorrhagic stroke:

occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed

A client is experiencing autonomic dysreflexia. The nurse should first: administer nitroprusside sodium IV. call the health care provider. place the client in Fowler's position. send a urine sample for culture.

place the client in Fowler's position. Explanation: Autonomic dysreflexia is a medical emergency. The rising blood pressure can cause cerebrovascular accident, blindness, or even death. Placing the client in Fowler's position lowers blood pressure. Administering nitroprusside IV is appropriate if the conservative measures are ineffective. Although notifying the health care provider is important, it is more essential that the nurse intervene immediately in the situation. A urine sample for culture should be obtained if the client has an elevated temperature and no other cause for the dysreflexia is found. A urinary tract infection may be causing symptoms.

When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate? supine with the hips at 90-degree flexion right side-lying position with the knees flexed prone with hips in abduction supine in semi-Fowler's position with chest and abdomen elevated

prone with hips in abduction explanation: Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler's position, even though the chest and abdomen are elevated.

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is: skin traction applied to a lower extremity, with the extremity suspended above the bed. skeletal traction applied to a lower extremity. skin traction applied to an extended lower extremity. skin traction applied bilaterally to the lower extremities.

skin traction applied to a lower extremity, with the extremity suspended above the bed. Explanation: Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

A nurse manager is implementing a plan to improve the use of standard precautions by the staff on the unit. After collecting observational data on the staff's use of personal protective equipment, which behavior would the nurse manager identify as an indication of the need for education? Select all that apply. use of gowns when caring for any client use of sterile gloves for urine specimen collection performance of hand hygiene after removing gloves disposal of contaminated dressings into a biohazard receptacle recapping of needles after use

use of gowns when caring for any client use of sterile gloves for urine specimen collection recapping of needles after use Explanation: Standard precautions include: performing hand hygiene after removing gloves, disposing of contaminated dressings in the proper biohazard container, using gowns if there will be splashing or spattering of blood or body fluids, using clean gloves to collect urine specimens, and never recapping needles once used.

A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned? salt water vinegar ammonia bleach

vinegar Explanation: A distilled vinegar solution acts as a good deodorizing agent after an appliance has been cleaned well with soap and water. If the client prefers, a commercial deodorizer may be used. Salt solution does not deodorize. Ammonia and bleaching agents may damage the appliance.

A client returns to the nursing unit following successful synchronized cardioversion using transthoracic chest wall patches. What should the nurse assess when the client returns to the room? Select all that apply. vital signs skin of chest wall arterial puncture site level of consciousness cardiac rhythm

vital signs skin of chest wall level of consciousness cardiac rhythm explanation: Vital signs give an important initial assessment of this client's status. The client may experience burns from the patches and current used for the cardioversion. Therefore, it is important to assess the skin of the chest wall for redness or burns. Because conscious sedation is used for this procedure, assessing the client's level of consciousness also is an important initial step. Attaching the client to cardiac monitoring is also important to assess rhythm abnormalities. There is no arterial puncture associated with the procedure.

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response? "I need you to trust me and the staff members in the facility." "It sounds like you are not concerned about your problems and why you are in the hospital." "This can just be between us, and I will share your progress only with the doctors and not your family." "Anything you say about your feelings is confidential, but your care involves the whole team so we can all work together."

"Anything you say about your feelings is confidential, but your care involves the whole team so we can all work together." explanation: Being truthful with the client and reinforcing the need for prevention of harm to self or others clarifies what the client can expect from the team. Challenging the client will contribute to a sense of low self-worth. "It sounds like you are not concerned about your problems and why you are in the hospital" is nontherapeutic and devalues the client's self-perception. Negotiating a special agreement or luring the client into the interview will not be therapeutic. "I need you to trust me and the staff members in the facility" does not offer a therapeutic way to establish trust.

A primiparous client who gave vaginal birth 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which client statements indicate the need for additional teaching? "Down syndrome is an abnormality that can result from a missing chromosome." "Down syndrome usually results in some degree of intellectual disability." "There are several methods available to determine whether my baby has Down syndrome." "Older mothers are more likely to have a baby with chromosomal abnormalities."

"Down syndrome is an abnormality that can result from a missing chromosome." Explanation: Down syndrome is a genetic abnormality that is caused by an extra chromosome that results in intellectual disability. The degree of disability is difficult to predict in a neonate, although most children born with Down syndrome have some degree of intellectual disability. Various methods can be used to determine whether a neonate has Down syndrome, which is commonly manifested by hypotonia, poor Moro reflex, flat facial profile, up-slanting palpebral fissures, epicanthal folds, and hyperflexible joints. Genetic studies can be indicative of this disorder. Mothers older than 35 years are at a higher risk for having a child with Down syndrome. However, chromosomal abnormalities can occur regardless of the mother's age.

The client with a urinary tract infection is given a prescription for trimethoprim. Which statement indicates that the client understands how to take the medication?

"I will take all the pills and then return to my doctor."

The nurse is teaching the parents of a 7-year-old child who has been newly diagnosed with absence seizures. The nurse is discussing behavior that may indicate seizure activity. Which of the following information is most appropriate for the nurse to teach about absence seizure activity? "Look for the eyes to roll back, a loss of consciousness, and convulsions." "Look for the body to tense and a loud moan or scream to occur." "Look for brief episodes of twitching accompanied by disorientation." "Look for rapid contraction and relaxation of the skeletal muscles."

"Look for brief episodes of twitching accompanied by disorientation." Explanation: Absence seizures are brief episodes of staring where awareness and responsiveness are impaired. People who have them usually don't realize when they've had one. There is no warning before the seizure, and the person is completely alert immediately afterward. The most common movements are eye blinks. Other movements include slight tasting movements of the mouth, hand movements such as rubbing the fingers together, and contraction or relaxation of the muscles.

The nurse is instructing a competent client in his legal rights regarding ECT (electroconvulsive therapy). Which statement by the client suggests further explanation is needed? "I can sign the informed consent myself before having the ECT completed." "I do not need a legal guardian to assist me in this process." "Since I was an Emergency Involuntary Commitment, I will be unable to sign the ECT form myself." "A family member cannot sign for me for the ECT treatment."

"Since I was an Emergency Involuntary Commitment, I will be unable to sign the ECT form myself." Explanation: There are some instances where a client may not sign for treatments as in a ECT treatment. If the client had been judged incompetent in a court of law, then a legal guardian will sign the form. Otherwise, the client must sign an informed consent. Options a, b, and d are incorrect as the family cannot sign as they are not guardians or health care power of attorney. Also, the client doesn't need a guardian as the client is competent. Option c is correct. Regardless of the manner in which the client has been admitted, voluntary or involuntary, as the client understands the risks and benefits of the ECT treatment and there has been no coercion in the process, the client may sign the consent form.

The nurse providing health promotion education to the parents of a 6-year-old child should include which statements about 6-year-old children in the education? "They are completely dependent on parents." "They rebel against schedules and routines." "They are very sensitive to criticism." "They love to tattle on other children."

"They are very sensitive to criticism" Explanation: A nurse should explain that a 6-year-old child has a precarious sense of self that can cause overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and actually love the routine of a schedule. Tattling is more common at age 4 or 5; by age 6, the child wants to make friends and be a friend.

A nurse working in a pediatric cardiac unit is teaching the parents of a child with a cardiac disorder about cardiac arrest among children. Which statement by the parents informs the nurse that the teaching has been successful? "We will decrease the risk of cardiac arrest by limiting exercise for our child." "We will be alert to respiratory problems to decrease the risk of cardiac arrest." "We will check for medication incompatibilities to prevent cardiac arrest." "We will prevent dehydration to minimize the risk of cardiac arrest."

"We will be alert to respiratory problems to decrease the risk of cardiac arrest." explanation: Respiratory failure is the leading cause of cardiac arrest among infants and children. Cardiac arrest is typically caused by the progressive tissue hypoxia and acidosis associated with respiratory failure. Although medication incompatibilities and hypovolemia from dehydration have the potential to deteriorate into serious situations, more common cardiac event situations arise from respiratory failure in this population.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? "I can offer you ibuprofen for pain with a small sip of water." "You are not allowed anything by mouth so that your pancreas can rest." "I will be starting antibiotic therapy once the blood cultures are obtained." "Activity is important, so you will be scheduled for physical therapy."

"You are not allowed anything by mouth so that your pancreas can rest." explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management, fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

Pleural effusion vs malignant pleural effusion

A pleural effusion is defined as an abnormal amount of fluid in the space between the layers of tissue (the pleura) that line the lungs. If cancer cells are present in this fluid (the pleural cavity), it is called a malignant (cancerous) pleural effusion.

acute glomerulonephritis

Acute glomerulonephritis is defined as inflammation and subsequent damage of the glomeruli leading to hematuria, proteinuria, and azotemia; it may be caused by primary renal disease or systemic condition

A client with malignant pleural effusions has dyspnea and chest pain. In which order of priority from first to last should the nurse manage the client's care? All options must be used. 1 Apply oxygen at 2 L via nasal cannula. 2 Administer morphine sulfate 2 mg IV. 3 Coach the client on deep breathing exercise. 4 Educate the client in anticipation of a thoracentesis.

Apply oxygen at 2 L via nasal cannula. Administer morphine sulfate 2 mg IV. Coach the client on deep breathing exercise. Educate the client in anticipation of a thoracentesis. Explanation: The client is short of breath. The head of the bed should be elevated to enable breathing and oxygen should be applied. Morphine should be administered for pain prior to initiating deep breathing exercises. Deep-breathing exercises improve lung expansion and decrease dyspnea. Education can be provided on the thoracentesis that is anticipated once the symptoms are managed.

A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first? Encourage the client to increase oral fluid intake. Insert an intermittent urinary catheter. Use an ultrasound bladder scanner to determine urine volume in the bladder. Assist the client up to the toilet to attempt to void.

Assist the client up to the toilet to attempt to void explanation: Urinary retention is common following abdominal surgery. The nurse should first assist the client to an anatomically comfortable position to void prior to resorting to other strategies such as cauterization. If the client is unable to void, the nurse can use a bladder scanner to determine the volume of retained urine, and then, if necessary, use an intermittent urinary catheter. While increasing fluid intake is important, it will not help the client void now.

Autonomic Dysreflexia

Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above).

A nurse is providing postprocedure instructions for a client who is to undergo a esophagogastroduodenoscopy. The nurse should begin this process:

Before the procedure Explanation: A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and his memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions prior to the client going to the procedure. The client needs to be aware at discharge of potential complications and signs and symptoms to report to the physician.

A client who is 16 weeks pregnant tells the nurse she has many mood swings. Which statement accurately describes estrogen and progesterone levels during this client's stage of pregnancy? Both estrogen and progesterone levels are rising. The estrogen level is much higher than the progesterone level. Both estrogen and progesterone levels are declining. The estrogen level is much lower than the progesterone level.

Both estrogen and progesterone levels are rising. explanation: Until the seventh month of pregnancy, estrogen and progesterone are secreted in progressively greater amounts. Between the seventh and ninth months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio contributes to mood swings.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention? Give feedings quickly Burp the infant frequently Encourage parental participation Don't give more feedings if the infant vomits

Burp the infant frequently explanation: These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

tailor sitting:

Buttocks on the floor with legs flexed and crossed ("pretzel sitting") tailor exercises strengthen the pelvic, hip, and thigh muscles and can help relieve low back pain.

A nurse is caring for a client who had a chest tube inserted 12 hours ago for treatment of a pleural effusion. Which assessment is most important in determining the client's response to the treatment? Intermittent bubbling in the water seal chamber Serous drainage in the collection chamber Client verbalization of decreased dyspnea Client resting quietly without reports of pain

Client verbalization of decreased dyspnea Explanation: Once some of the fluid has been removed via the chest tube drainage system, the client should feel relief and have a decrease in dyspnea. Serous drainage and bubbling in the water seal chamber are normal findings with the insertion of a chest tube, but do not indicate how the client is responding to the treatment.

Knowing Maslow's hierarchy of needs can assist a nurse in understanding a client's behavior. Place the stages of Maslow's hierarchy of needs in order from basic to most complex. Use all options.

Physiologic needs Safety and security Love and belonging Self-esteem Self-actualization

The graduate registered nurse (RN) is assigned the care of a client with acute renal failure and hypernatremia. Which actions can the graduate RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Administer saline IV fluid. Provide oral care. Monitor for dehydration. Assess daily weights for trends

Provide oral care Explanation: Providing oral care is within the UAP's scope of practice. Monitoring and assessing clients, as well as administering IV fluids, requires the additional education of the licensed nurse.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube? Change the tube feeding administration set at least every 24 hours. Maintain the head of the bed at a 15-degree elevation continuously. Check the gastrostomy tube for position every 2 days. Maintain the client on bed rest during the feedings.

Change the tube feeding administration set at least every 24 hours explanation: The nurse should change tube feeding administration sets at least every 24 hours. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings.

Cardioversion vs Defibrillation

Defibrillation - is the treatment for immediately life-threatening arrhythmias with which the patient does not have a pulse, ie ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Cardioversion - is any process that aims to convert an arrhythmia back to sinus rhythm.

The mother of an 8-year-old child with a fluid restriction of 1,000 mL/day is staying in the child's room. Which intervention would be most appropriate for the nurse to include in the child's plan of care? Discuss the fluid restriction with the mother and child, and allow them to decide how to allocate the fluids over the 24 hours. Explain to the mother that hospital personnel will assume the responsibility for providing fluids to the child. Let the child eat jello if fluid limits have been met. Tell the mother exactly how much fluid the child can have each hour, and show her examples of the amount.

Discuss the fluid restriction with the mother and child, and allow them to decide how to allocate the fluids over the 24 hours. Explanation: Planning the child's fluid restriction with the mother and child is most appropriate because the mother and child would best know the child's usual pattern of fluid intake. Doing so also provides the mother with a feeling of some control over her child's situation and helps to promote compliance. Anyone, not just hospital personnel, can provide the child with fluids. However, a strict record of the child's intake must be kept to ensure adherence to the restriction. Jello counts as a fluid, thus it must also be limited. Telling the mother exactly how much fluid the child can have each hour restricts the extent of the mother's and child's participation in care. Additionally, doing so ignores the child's usual needs, such as the usual pattern of fluid intake, possibly interfering with adherence to the fluid restriction.

Anticholinergic drugs- how they work

Doctors prescribe anticholinergic drugs to treat a variety of conditions, including chronic obstructive pulmonary disease (COPD), bladder conditions, gastrointestinal disorders, and symptoms of Parkinson's disease. There are many different types of anticholinergic drug, but they all work by blocking the action of acetylcholine, a type of neurotransmitter. Blocking this neurotransmitter inhibits involuntary muscle movements and various bodily functions.

After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal? Encourage self-care skills in the child. Teach the child something new each day. Encourage more lenient behavior limits for the child. Achieve age-appropriate social skills.

Encourage self-care skills in the child The goal in working with children with intellectual disabilities is to train them to be as independent as possible, focusing on developmental skills. The child may not be capable of learning something new every day but he or she does need to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child. Most children with Down syndrome are unable to achieve age-appropriate social skills due to their disability. Rather, they are taught socially appropriate behaviors.

A client's fasting blood sugar (FBS) is 63 mg/dL (3.5 mmol/L) at 0700. The client is alert and oriented. What should the nurse do first?

Give 15 g of carbohydrate and recheck the blood glucose in 15 minutes.

A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first? Tell the client it is impossible to feel the pain. Show the client that the toes are not there. Explain to the client that the pain is real. Give the client the prescribed opioid analgesic.

Give the client the prescribed opioid analgesic Explanation: The nurse's first action should be to administer the prescribed opioid analgesic to the client because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis? Imbalanced nutrition: less than body requirements Ineffective airway clearance Impaired urinary elimination Risk for injury

Ineffective airway clearance: Explanation: In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment? Weight and height Known allergies Apical heart rate Cardiac rhythm

Known allergies Explanation: Since cardiac catheterization involves the injection of a radiopaque dye. It is most important for the nurse to determine if this client has allergies to iodine or shellfish. The other three parameters are also part of the assessment, but are not the priority.

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? Semi-Fowler's Leaning forward while sitting Supine Prone

Leaning forward while sitting Explanation: The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.

Hormones during pregnancy

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A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, "They said I was gay because I had sex with an older neighbor when I was 8 years old. I am not gay!" Which nursing interventions would be appropriate? Select all that apply. Monitor the client's level of anger and potential aggression. Help the client express anger safely. Assist the client in processing his feelings about the sexual abuse. Ask the client if he would like to attend a support group. Discuss the client's attitude about going to jail after discharge.

Monitor the client's level of anger and potential aggression. Help the client express anger safely. Assist the client in processing his feelings about the sexual abuse. Ask the client if he would like to attend a support group. explanation: Safety of others is a priority, and the nurse must monitor the client's anger and potential for aggression. The nurse should also find safe ways for the client to express the client's anger and any other feelings about the abuse. A referral to a support group is appropriate because anger management groups are one way to assist the client in learning to manage anger. Nothing about jail is mentioned in the question. Discussion of jail does not help the client address the client's issues with anger and the abuse causing the anger.

The mother of a newborn is voicing concerns about her baby's ability to hear. What should the nurse tell the mother? Newborns cannot hear well until they are at least 6 weeks old. Her concern is unfounded because hearing problems are rare in newborns. Most American states and Canadian jurisdictions mandate hearing tests for infants. She can test the baby's hearing by clapping her hands 24 inches (60 cm) from the infant's head.

Most American states and Canadian jurisdictions mandate hearing tests for infants. Explanation: The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend hearing screening for all newborns. Currently more than 30 states mandate screening, which is done by otoacoustic emissions or auditory brainstem response. Newborns can hear as soon as the amniotic fluid drains from the ear canal. Even though hearing problems are not common in newborns, the mother's concerns should be addressed. Clapping to elicit a response is crude and unreliable. If done for minimal screening, the distance should be no more than 12

A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because: Nurses are highly vulnerable to criminal and civil prosecution in the course of their work. Nurses interact with clients and families from diverse cultural and religious backgrounds. Nursing practice involves numerous interactions between laws and individual values. Nurses are responsible for carrying out actions that have been ordered by other individuals.

Nursing practice involves numerous interactions between laws and individual values. Explanation: A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.

Which goal is the priority for a client with a fractured femur who is in traction? Prevent effects of immobility while in traction. Develop skills to cope with prolonged immobility. Choose appropriate diversional activities during the prolonged recover. Adapt to inactivity from the impaired mobility.

Prevent effects of immobility while in traction The priority for this client is to prevent the effects of prolonged immobility, such as preventing skin breakdown and encouraging the client to take deep breaths, and use active range-of-motion exercises for the joints that are not immobilized.

The nurse is teaching a group of high school students about risk-taking behaviors. Which of the following topics would be considered an example of healthy behaviors? Effects of cigarette smoking Responsible drinking patterns Motor vehicle accidents Preventative vaccinations

Preventative vaccinations Explanation: Preventative vaccinations are not associated with a risk-taking behavior. Vaccinations are used as vehicles to prevent communicable diseases rather than living dangerously. The other choices are all associated with risk-taking behaviors: smoking, drinking, and motor vehicle accidents. These are especially important to discuss with young adults.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Phytonadione (vitamin K) Protamine sulfate Thrombin Plasma protein fraction

Protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

A hospital nurse is on the safety committee. Which should the nurse recommend to the hospital administration to reduce needle-stick injuries at the institution? Select all that apply. Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Remind staff to use the "scoop" technique for recapping needles Allow staff to carefully recap syringes by holding the cap in the dominant hand and the syringe in the nondominant hand

Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Remind staff to use the "scoop" technique for recapping needles explanation: The nurse should not recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharps-disposal containers immediately after use are safe ways to handle sharps with less risk of needle-stick injuries. The nurse should use the one-handed needle-recapping technique only when absolutely necessary, such as when a sharps-disposal container is not readily available.

A client has been receiving oxytocin to augment her labor. The nurse notes that contractions are lasting 100 seconds. Which immediate action should the nurse take? Stop the oxytocin infusion Notify the provider Monitor fetal heart tones as usual Turn the client on her left side

Stop the oxytocin infusion Explanation: Oxytocin should be withheld immediately, as it stimulates contractions. A contraction that continues for more than 90 seconds signals tetany and could lead to decreased placental perfusion and possibly uterine rupture. The nurse should monitor the fetal heart tones, stop the oxytocin, and notify the provider. The client should be turned on her left side to increase blood flow to the fetus, which can be decreased with tetany. This decreased blood flow can potentially compromise the fetus.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? Assess the temperature, blood pressure, and check for blood in the urine. Then stop the transfusion. Slow the transfusion and monitor the client's vital signs. Stop the transfusion, notify the blood bank, and administer antihistamines. Stop the transfusion, infuse normal saline solution, and call the physician.

Stop the transfusion, infuse normal saline solution, and call the physician. Explanation: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions should not be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

TCA interactions:

TCAs interact with many different drugs, so ask your doctor or pharmacist about possible interactions before taking a tricyclic antidepressant. Don't take TCAs if you're also taking: MAOIs such as Marplan (isocarboxazid) or Parnate (tranylcypromine) Zyvox (linezolid) Drugs for bowel preparation that contain phosphate, usch as OsmoPrep or Visicol Tagamet Alcohol St. John's wort

The parent of a client who is disabled due to a traumatic amputation states to the nurse, "I am concerned that situations will occur and that I may not know what to do to help my son when we are at home." Which response by the nurse is the most appropriate to address the parent's concern?

Talk to your son about what he needs and ask how you can be of assistance.

Best position for normal delivery of baby:

The best position for your baby to be in for labour and birth is head down, facing your back - so that their back is towards the front of your tummy. This is called the occipito-anterior position. It allows them to move more easily through the pelvis.

On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, what is the most important factor for the nurse to consider? The boys probably fear punishment. Sniffing glue is illegal. The boys' observations could be wrong. Glue-sniffing is a minor form of substance abuse.

The boys probably fear punishment. explanation: Telephoning the crisis shelter indicates that the boys are alarmed but are reluctant to talk with their parents. The boys may fear that their parents will assume that they have been sniffing glue and punish them. The nurse should focus on helping the boys talk with their parents. The legality of sniffing glue varies, but crisis hotlines are geared at providing supportive services. To prove that the observations are incorrect requires an intervention beginning with the boys' parents. Sniffing glue is classified as inhalant abuse, a very dangerous, not minor, form of substance abuse.

A nurse is teaching a parent of a toddler diagnosed with conjunctivitis to administer the ophthalmic ointment. Which action by the mother indicates that further instruction is necessary? The mother washes her hands before and after administration. The mother applies the ointment to the lower conjunctival sac. The mother holds the eyelids open with her fingers. The mother cleans the eye prior to medication administration.

The mother holds the eyelids open with her fingers. Explanation: Washing hands before and after administration to an infected eye is very important to prevent the spread of conjunctivitis. Applying the ointment to the lower conjunctival sac ensures the medication will adequately cover the eye. Cleaning the eye prior to administration helps the medication be absorbed and decreases the bacteria in the eye. Holding the eyelids open will not allow application of the medication to the lower conjunctival sac.

Pericardium:

The word "pericardium" means around the heart. The outer layer of the pericardium is called the parietal pericardium. The inner part of the pericardium that closely envelops the heart is, as stated, the epicardium; it is also called the visceral pericardium. Two layers: outer fibrous and inner serous

A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

Turn him regularly

Nitroprusside (Nipride, Nitropress)

Vasodilators (Direct Acting) -acts mainly arterioles and venules

A client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply. Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. Insert a urinary drainage catheter.

Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. Explanation: For clients scheduled for a cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent<glicon>, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. If the client is taking anticoagulant drugs, the nurse should ask the client if the health care provider has given instructions to withhold these medications. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.

A physician prescribes several drugs for a client admitted to the emergency department with Laennec's cirrhosis. Which drug order should the nurse question? Folic acid Ketorolac Warfarin Vitamin K

Warfarin explanation: Laennec's cirrhosis is caused by excessive alcohol use. Folacin or folic acid and vitamin K are all appropriate for this client due to vitamin deficiencies caused by cirrhosis. The client is at risk for bleeding related to the inability of the liver to alteration in clotting factors; therefore, warfarin is contraindicated. Ketorolac is a nonopioid analgesic and is appropriate for pain control in this client.

Menstrual cycle hormones

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pleura

double-layered membrane surrounding each lung

A client receiving radiation therapy has fatigue. What should the nurse include in the teaching plan? increase fluid intake minimize naps or periods of rest during the day conserve energy by prioritizing activities limit dietary intake of high-fiber foods

conserve energy by prioritizing activities explanation: Prioritizing physical activities helps to conserve energy, which promotes adaptation to fatigue. The client should learn to take short naps or short rest periods during the day for additional energy conversation. Increased fluid intake is important but may interrupt rest periods by causing frequent urination. Limiting intake of high-fiber foods can add to constipation, which may be a problem because of inactivity in fatigued clients.

A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow she should use. Which intervention should the nurse perform to ensure that the oxygen is properly administered? Consult with a respiratory therapist. Read the package directions. Ask a nursing assistant what to do. Use a conventional oxygen mask.

consult with a respiratory therapist

anticholinergic effects:

dry mouth, blurred vision, constipation, urinary retention can't see can't pee can't spit can't shit

A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. What should the nurse assess first after admission to the birthing area? time of last food and fluid intake fetal position and station contraction frequency and intensity ability to follow directions

contraction frequency and intensity When admitting a multigravid client to the birthing area, the nurse needs to obtain information about the frequency, intensity, and duration of labor contractions; the time when the labor began; whether the membranes have ruptured; and the client's estimated childbirth date. From this information, the nurse gets a quick overview of the client's status and can then proceed to plan effective care. Although the time when the client last had food or fluids is important, this information can be obtained later because it is less influential in determining the initial plans for care. Although information about the fetal position is important, this information is less influential in determining the initial plans for care. The client's ability to follow directions is important, but this information can be obtained later because it plays a less influential role in initial plans for care.

The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? dopamine enalapril furosemide metoprolol

dopamine explanation: Cardiogenic shock is when the heart has been significantly damaged and is unable to supply enough blood to the organs of the body. Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and does not have a direct effect on contractility or tissue perfusion. Metoprolol is a adrenergic blocker that slows heart rate and lowers blood pressure; neither is a desired effect in the treatment of cardiogenic shock.