Comprehensive Practice Hesi

Intake and output Rationale: Amphotericin B, an antifungal medication, is highly toxic, and infusion reactions and renal damage occur, to varying degrees, in all clients. As a means of detecting renal injury, tests of kidney function should be performed weekly and intake and output should be monitored closely. Other adverse effects include delirium, hypotension, hypertension, wheezing, and hypoxia. The remaining options are not associated with an adverse effect of the medication.

A client diagnosed with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B. Which parameter does the nurse check to detect the most common adverse effect of this medication? Temperature Blood pressure Peripheral pulses Intake and output

"Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?" Rationale: Noncompliance with antipsychotic medication is one of the reasons clients with schizophrenia have relapses. The nurse should give a response to the schizophrenic client that will help the client identify the causes of relapse. In asking, "Only you can help?" the nurse is employing restating, which can be therapeutic but is not useful in this client's situation. "You decided not to take your medication?" is another example of restating. In stating, "If you can make this observation, you probably don't need your medication any longer," the nurse is using an illogical, judgmental, and biased response that is not therapeutic.Test-Taking Strategy: Focus on the client's diagnosis to identify the therapeutic response. Note that the correct option is therapeutic and helps the client identify the cause of his relapse. Review care of the client with schizophrenia if you had difficulty with this question.

A client diagnosed with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? "Only you can help?" "You decided not to take your medication?" "If you can make that observation, you probably don't need your medication any longer." "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"

Yellow skin Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. Adverse effects include hepatotoxicity, thrombocytopenia, and anemia. The nurse instructs the client to contact the health care provider if he experiences jaundice (yellow skin or eyes), unusual tiredness, fever, loss of appetite, or hot, painful, or swollen joints. Headache, nasal congestion, and difficulty sleeping are not associated with the use of this medication.

A client diagnosed with tuberculosis will be taking pyrazinamide, and the nurse provides instructions about the adverse effects of the medication. For which occurrence does the nurse tell the client to contact the health care provider? Headache Yellow skin Difficulty sleeping Nasal congestion

Decrease Rationale: Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect.

A client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: Increase Decrease Remain unchanged Double from what they normally are

"I don't think anyone can save the world from the terrorists by himself." Rationale: The nurse should not go along with or reinforce the client's delusion. The nurse should respond to the client by presenting reality. "Tell me your plan for saving the world," "Why do you think that you can accomplish this by yourself?" and "You must be powerful. Do you really believe you can do this by yourself?" all reinforce the delusion and encourage further conversation about it.

A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? "Tell me your plan for saving the world." "Why do you think that you can accomplish this by yourself?" "I don't think anyone can save the world from the terrorists by himself." "You must be powerful. Do you really believe that you can do this by yourself?"

The client takes isosorbide dinitrate . Rationale: Sildenafil is used to treat male erectile dysfunction. It is contraindicated in the client who is using sodium nitroprusside or organic nitrates in any form because both sildenafil and nitrates promote hypotension. When these medications are combined, life-threatening hypotension may result. Type 2 diabetes mellitus, a history of renal calculi, and the use of glargine insulin are not contraindications to the use of sildenafil.

A client has a health care provider's appointment to get a prescription for sildenafil . The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated? The client has type 2 diabetes mellitus. The client has a history of renal calculi. The client is taking glargine insulin. The client takes isosorbide dinitrate .

Steak Rationale: Lovastatin is a lipid-lowering agent. The client is instructed to consume foods that are low in fat, cholesterol, and complex sugars. The item highest in fat here is steak; therefore the client should limit the intake of steak. Fruits, vegetables, and chicken are low in fat.

A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication? Steak Spinach Chicken Oranges

Hypersensitivity to negative evaluation Rationale: Avoidant personality disorder is a psychiatric condition in which a person feels extremely shy, inadequate, and sensitive to rejection. Other characteristics of avoidant personality disorder include excessive anxiety in social situations and hypersensitivity to negative evaluation. Neediness is a characteristic of dependent personality disorder. Perfectionism and preoccupation with details are characteristics of obsessive-compulsive disorder.

A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which behavior is a characteristic of the disorder? Neediness Perfectionism Preoccupation with details Hypersensitivity to negative evaluation

Assist in intubating the client and beginning mechanical ventilation Rationale: A client who sustains smoke inhalation is immediately treated with 100% humidified oxygen, delivered by way of face mask. Endotracheal intubation with mechanical ventilation is needed if the client exhibits respiratory stridor, crowing, or dyspnea, all of which indicate airway obstruction. Normal arterial oxygenation is 80-100 mm Hg (10.6-13.33 kPa). An arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa) is an indication for intubation and mechanical ventilation.

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (PaO2) of less than 60 mm Hg (7.95 kPa). On the basis of the ABG result, the nurse prepares to: Continue monitoring the client Increase the amount of humidified oxygen Continue administering humidified oxygen Assist in intubating the client and beginning mechanical ventilation

Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event Rationale: An honest, nonjudgmental, and empathetic attitude helps the nurse build a trusting relationship with the client. The nurse would assess the immediate posttraumatic reaction and later coping. Numbing and denial are common reactions after a traumatic event, and knowing the range of the client's behavior can help the nurse assess the impact and meaning of the trauma. Writing about the trauma in a journal can lessen the intensity of the client's emotions and his or her preoccupation with the event over time.The nurse would ask the client about the use of alcohol and drugs before and since the event. It is important for the nurse to obtain this information, because attempts to self-medicate to reduce anxiety and induce sleep are common after a traumatic event. The client needs to understand that he or she is not responsible for the event, but the nurse should emphasize that the client is responsible for learning to cope. This strategy will assist the client in easing feelings of powerlessness. The nurse would encourage attendance at support groups so that the client can share experiences, feel understood, and begin to heal.

A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply. Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event Promoting discussion of the reasons the client was responsible for the traumatic event Discouraging the use of support groups until the client is able to use effective coping techniques

Bleeding Rationale: Alteplase is a thrombolytic agent used to dissolve existing thrombi. Bleeding is the most common adverse effect, and the nurse must monitor the client for obvious or occult signs of bleeding. Hearing loss and decreased urine output are not associated with the use of this medication. The medication may also cause a decrease in blood pressure and an allergic reaction, denoted by a rash or wheezing.

A client is receiving an intravenous infusion of alteplase.For which adverse effect of the medication does the nurse monitor the client most closely? Bleeding Hearing loss Decreased urine output Increased blood pressure

The health care provider will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage Rationale: Salicylism is a syndrome that begins to develop when the aspirin level climbs just slightly above the therapeutic level. Overt signs include tinnitus (ringing in the ears), sweating, headache, and dizziness. If salicylism develops, aspirin is withheld until the symptoms have subsided; therapy should then be resumed with a small reduction in dosage. Tinnitus is not an expected finding. Drinking water will not prevent tinnitus. A nonsteroidal antiinflammatory medication will not be prescribed, because these medications' chemical properties are similar to those of aspirin.

A client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid daily in a divided dose. At the health care provider's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that: This is expected and nothing to be concerned about It is important to drink at least 10 glasses of water a day to prevent ringing in the ears This is a sign of toxicity, so the aspirin will be discontinued and replaced with a nonsteroidal anti-inflammatory medication The health care provider will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

Is at low risk for AIDS Rationale: The test most commonly used to screen clients for HIV infection is the ELISA. A positive ELISA result must be confirmed with the Western blot technique. The plasma HIV RNA level is an indication of the amount of virus in the person's serum, which is a reflection of active viral replication, or viral load. The steeper the rate of increase in plasma HIV RNA, the greater the risk of disease progression. A plasma HIV RNA level of less than 10,000 copies/mL is considered indicative of low risk for the development of AIDS. Levels between 10,000 and 100,000 copies/mL represent a doubled risk for AIDS, and a result of more than 100,000 copies/mL indicates a high risk for AIDS.

A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client: Is at low risk for AIDS Is at high risk for AIDS Is at risk for HIV infection Requires further testing to confirm the presence of HIV

Place small pieces of tape over the rough edges of the cast Rationale: If a client with a cast experiences skin irritation from the edges of the cast, the nurse should petal (place small pieces of tape over) the rough edges of the cast to minimize the irritation. Bivalving is performed if the limb swells occurs and the cast becomes too tight. Using a nail file to smooth the rough edges could cause pieces of the cast to fall into the cast, possibly resulting in the disruption of skin integrity. It is not necessary to contact the health care provider, and there is no reason to reapply the cast.

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse Bivalve the cast Use a nail file to smooth the rough edges Ask the health care provider to reapply the cast Place small pieces of tape over the rough edges of the cast

Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair. Rationale: The client is instructed to wash the external ear and canal daily in the shower or while washing his or her hair. The client should never use a small object such as a cotton-tipped applicator to clean the external ear canal. The client is instructed to blow the nose gently and is told not to occlude a nostril when blowing the nose. The client should also wear sound protection around loud or continuous noises, avoid activities with a high risk for ear trauma, keep the volume of headphones at the lowest setting, and avoid environmental conditions involving rapid changes in air pressure.

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. Always sneeze with the mouth closed. Occlude one nostril when blowing the nose. Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair. Be cautious when using cotton-tipped applicators to clean the external ear canal.

In a vertical position with the needles pointing up Rationale: Mixtures of insulin in prefilled syringes may be stored in a refrigerator, where they will be stable for at least 1 to 2 weeks. The syringes should be stored vertically, with the needles pointing up to prevent clogging of the needle with the insulin. Before administration of the medication, the syringe should be agitated gently to resuspend the insulin.Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (lying flat, horizontal). Next visualize each of the remaining options and think about the effect of having the needles point up or down. This will help direct you to the correct option. Review the principles of prefilling insulin syringes if you had difficulty with this question.

A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: Lying flat In a horizontal position In a vertical position with the needles pointing up In a vertical position with the needles pointing down

"Don't say that. If you can't control yourself, we'll help you." Rationale: The nurse should respond using a firm, calm approach, providing the client with clear expectations. The correct option is the only one that involves a firm, calm approach and offers the client help if she needs it. The other three statements challenge the client.

A hospitalized female client demonstrating mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Why are you saying that?" "Stop saying that. It's not true!" "You wouldn't like someone saying that to you. Would you?" "Don't say that. If you can't control yourself, we'll help you."

Encourage the child to drink water or milk in small amounts Rationale: Administering water or milk can dilute the toxic effects of acid or alkali ingestion. These substances, when ingested, may cause burning of tissue along the gastrointestinal tract. Because these caustic substances continue to cause damage until they are neutralized, induction of emesis is contraindicated. Although calling the child's health care provider and bringing the child to the emergency department may each be necessary, they are not the actions to be taken immediately, because they would delay necessary treatment.

A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately: Induce vomiting Call the child's health care provider Bring the child to the emergency department Encourage the child to drink water or milk in small amounts

Outside the abdominal cavity, not covered with a sac Rationale: Gastroschisis is a defect of the abdominal wall in which the viscera are outside the abdominal cavity and not covered with a sac. An umbilical hernia is usually located inside the abdominal cavity and under the dermis or under the skin. An omphalocele is located outside the abdominal cavity and inside a translucent sac covered with peritoneum and amniotic membrane.

A nurse admitting a newborn to the nursery notes that the health care provider has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are: Inside the abdominal cavity and under the skin Inside the abdominal cavity and under the dermis Outside the abdominal cavity, not covered with a sac Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

Document the findings Rationale: The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present, hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes should be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes (3+ to 4+) suggest preeclampsia and must be reported to the health care provider. It is not necessary to contact the health care provider, because the finding is normal. Likewise, rechecking the client's reflexes after ambulation and performing active and passive ROM exercises incorrect and unnecessary actions.

A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: Document the findings Contact the health care provider Ask the client to walk for 5 minutes, then recheck the reflexes Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes

Placing the client in a lateral position with the bed flat Rationale: If the client exhibits signs of hypovolemic shock, the nurse would contact the health care provider. The nurse would monitor fetal status closely and take action to minimize the effects of hypovolemic shock and promote tissue oxygenation. The client would be placed in a lateral position, with the head of the bed flat to increase cardiac return and thus increase circulation and oxygenation of the placenta and other vital organs. After positioning the client, the nurse would insert IV lines in accordance with the health care provider's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this is not the first action.

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the health care provider, which does the nurse specify as the first action in the event of shock? Checking the client's urine output Inserting an intravenous (IV) line Obtaining informed consent for a cesarean delivery Placing the client in a lateral position with the bed flat

Use a straw to drink. Use caution when leaning forward or backward. Do not drive, because full range of vision is impaired with the device. Rationale: A halo fixation (stabilization) device is used to prevent the head and neck from moving after a neck injury. Straws are used to drink, and meat and other foods are cut into small pieces to facilitate swallowing. The halo fixation device is not removed. Sexual activity does not have to be avoided; the client is instructed to use a position of comfort. Powders and lotions are used sparingly or not at all to prevent buildup of moisture and subsequent skin breakdown. The weight of the halo device alters balance; therefore the client should use caution when leaning forward or backward. The client is instructed to wear loose clothing with a large neck. The client is not to drive, because full range of vision is impaired with the device. The halo fixation device should not shift; if it does, the health care provider must be notified. The client is taught to sleep with the head supported with a small pillow to prevent unnecessary pressure and discomfort.

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply. Use a straw to drink. Avoid sexual activity while the vest is in place. Apply powder under the vest to prevent irritation. Use caution when leaning forward or backward. Wear snug clothing to prevent the device from shifting. Do not drive, because full range of vision is impaired with the device.

Protamine sulfate Rationale: If the IV tubing is removed from an infusion pump and the tubing is not clamped, the client will receive a bolus of the solution of the medication contained in the solution. Heparin is an anticoagulant, and the client who receives a bolus dose of heparin is at risk for bleeding. The nurse would notify the health care provider. A blood sample for partial thromboplastin time (PTT) would be drawn and the results of testing evaluated. If the PTT is too high, the infusion may be stopped for a time, or a dose of protamine sulfate, the antidote for heparin, may be prescribed. Enoxaparin is an anticoagulant. Phytonadione is the antidote for warfarin sodium.Aminocaproic acid is an antifibrinolytic, inhibiting clot breakdown

A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred? Enoxaparin Phytonadione Protamine sulfate Aminocaproic acid

"I need to eat three meals a day with foods high in protein, fat, and carbs." Rationale: The client with hepatitis is easily fatigued and may require several weeks to reach his or her former activity level. The client should avoid hepatotoxic substances such as alcohol. Sexual intercourse is avoided until antibody testing results are negative. It is important for the client to get adequate rest both during the day and at night so that the liver may heal. The client should consume a high-carbohydrate, low-fat diet.

A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching? "I can't drink alcohol." "I have to avoid having sex until the test for antibodies comes back negative." "I need to rest a lot during the day and get enough sleep at night." "I need to eat three meals a day with foods high in protein, fat, and carbs."

Mucous membranes Rationale: Assessment of the skin, sclera, and mucous membranes provides the best data regarding the presence of jaundice. The color of the lips provides data regarding the presence of cyanosis. Although assessment of the skin provides adequate data regarding jaundice, the soles and palms are not the best areas of skin for assessment.

A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice? Lips Soles Palms Mucous membranes

Paresthesia Rationale: Acute compartment syndrome is a serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area. Resultant edema causes pressure on the nerve endings and subsequent pain. Sensory deficits such as paresthesia generally appear before changes in vascular or motor signs. The client will also complain of severe diffuse pain that is not relieved by analgesics.

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client? paresthesia Cold, bluish toes Weak pedal pulse Severe pain relieved by medication

Teaching the client to move the head from side to side (scan) when eating Rationale: Hemianopsia is the loss of vision in a portion of the visual field. Approaching the client from the side of nonintact vision, placing objects needed for self-care within the client's nonintact visual field, and positioning the client so that the damaged part of the visual field faces the door are incorrect because the client depends on and needs to use the intact portion of the visual field for sensory input. The client is taught to move the head from side to side (scan) to compensate for a diminished visual field. Scanning is also important when the client is eating.

A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which measure does the nurse take in the care of the client? Approaching the client from the side of nonintact vision Teaching the client to move the head from side to side (scan) when eating Placing objects needed for self-care within the client's nonintact visual field Positioning the client in the room so that his nonintact visual field faces the door

Urinary specific gravity is low Rationale: After transsphenoidal hypophysectomy, the client is monitored for transient diabetes insipidus. In a client with diabetes insipidus, the urinary specific gravity is low and urine output is excessive. A blood pressure of 138/80 mm Hg is not cause for concern. The client will have nasal packing and a mustache dressing and may complain of dry mouth because of the necessity for mouth breathing. The nurse would provide frequent oral rinses and apply petroleum jelly to dry lips. The client should perform frequent deep-breathing exercises (coughing is contraindicated) to help prevent pulmonary complications.

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which finding would be of greatest concern to the nurse? Urinary specific gravity is low Blood pressure is 138/80 mm Hg. The client complains of a dry mouth. The client frequently performs deep-breathing exercises

Tachycardia Diminished peripheral pulses Rationale: When hypovolemic shock develops, the body attempts to compensate for decreased blood volume and to maintain oxygenation of essential organs by increasing the rate and effort of the heart and lungs by shunting blood from less essential organs, such as the skin and extremities, to more essential ones, such as the brain and kidneys. This compensatory mechanism results in the early signs and symptoms of hypovolemic shock, which include tachycardia, diminished peripheral pulses, normal or slightly decreased blood pressure, increased respiratory rate, and cool, pale skin and mucous membranes. The compensatory mechanism fails if hypovolemic shock progresses and there is insufficient blood to perfuse the brain, heart, and kidneys. Later signs of hypovolemic shock include decreasing blood pressure, pallor, cold and clammy skin, and urine output of less than 30 mL/hr.

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. Tachycardia Cool, clammy skin Decreased respiratory rate Diminished peripheral pulses Urine output of less than 30 mL/hr

The client reports a history of sexual abuse by her father. Rationale: Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality should be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment.

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? The client reports a history of sexual abuse by her father. The client reports that her relationship with her spouse is stable. The client reports a satisfying intimate relationship with her spouse. The client reports that her and her spouse have never been able to conceive children

Increased heart rate Rationale: Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children ages 3 months to 6 years. The classic signs of intussusception are a sausage-shaped abdominal mass and the passage of bloody ("currant jelly") stool and diarrhea. The nurse monitors the child closely for signs of sepsis, peritonitis, and shock. Possible indicators of peritonitis include fever, increased heart rate, changes in the level of consciousness or in blood pressure, and respiratory distress.

A nurse is monitoring a child with intussusception for signs of peritonitis. For which finding, indicative of this complication, does the nurse notify the health care provider? Increased alertness Increased heart rate A sausage-shaped abdominal mass Diarrhea and the passage of bloody mucous stool

Stokes sign Rationale: In superior vena cava syndrome, the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms, which generally occur in the early morning, include edema of the face, especially around the eyes (periorbital edema), and complaints of tightness of a shirt or blouse collar (Stokes sign). As the compression worsens, the client experiences edema of the hands and arms, dyspnea, erythema of the upper body, and epistaxis (nosebleeds). Late (and life-threatening) signs and symptoms include hemorrhage, cyanosis, mental status changes resulting from lack of blood to the brain, decreased cardiac output, and hypotension (low blood pressure). Death may result if the compression is not relieved.

A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client? Dyspnea Cyanosis Hypotension Stokes sign

1 Rationale: Hypertension, generalized edema, and proteinuria are the three classic signs of preeclampsia. Deep tendon reflexes may be very brisk (hyperreflexia) and clonus may be present, suggesting cerebral irritability resulting from decreased brain circulation and edema. Decreased urinary output (less than 30 mL/hr) indicates poor perfusion of the kidneys and may precede acute renal failure. Negative findings of the urinary protein assay, urine output of 45 mL/hr, and a blood pressure of 128/78 mm Hg are all signs that preeclampsia is resolving.

A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which finding elicited during the assessment indicates that the condition has not yet resolved? Type the option number that is the correct answer. ______ 1) Hyperreflexia is present 2) Urinary protein is not detectable 3) Urine output is 45 mL/hr 4) Blood pressure is 128/78 mm Hg.

Soft, relaxed, nontender uterus Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client? Painful vaginal bleeding Sustained tetanic contractions Complaints of abdominal pain Soft, relaxed, nontender uterus

Drooling Excessive oral secretions Rationale: EA and TEF, the most life-threatening anomalies of the esophagus, often occur together, although they may occur singly. EA is a congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thereby failing to form a continuous passageway to the stomach. TEF is an abnormal connection between the esophagus and trachea. EA with or without TEF results in excessive oral secretions, drooling, and feeding intolerance. When fed, the infant may swallow but will then cough and gag and return the fluid through the nose and mouth. Bowel sounds over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccuping and spitting up after a meal are clinical manifestations of gastroesophageal reflux. Coughing, wheezing, and short periods of apnea are clinical manifestations of hiatal hernia.

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. Drooling Wheezing Hiccuping Short periods of apnea Excessive oral secretions Bowel sounds over the chest

Anxiety Rationale: Anxiety is vague uneasiness or discomfort that warns of trouble and enables an individual to approach and deal with the threat. Fluid volume loss indicates a hypovolemic state, whereas fluid volume overload indicates a hypervolemic state. Premature grief is a state in which an individual grieves before an actual loss. There is no information in the question to indicate that fluid volume loss, fluid volume overload, or premature grief are factors for concern.

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? Anxiety Premature grief Fluid volume loss Fluid volume overload

Helps predict the risk for the development of chronic complications of diabetes mellitus Rationale: Glycosylated hemoglobin is the best indicator of the average blood glucose level. Because glucose attaches itself to the hemoglobin molecule, measurement of glycosylated hemoglobin indicates the average blood glucose level during the previous 120 days, the lifespan of the red blood cell. The test is used to assess long-term glycemic control, as well as to predict the risk for the development of chronic complications.

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: Is a measure of the client's hematocrit level Is a measure of the client's hemoglobin level Helps predict the risk for the development of chronic complications of diabetes mellitus Provides a determination of short-term glycemic control in the client with diabetes mellitus

Headache and nausea Rationale: Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone (ADH). Desmopressin, a synthetic form of antidiuretic hormone, causes increased resorption of water and a resultant decrease in urine output (an expected outcome). One adverse effect of the medication is water intoxication. Early signs of water intoxication include headache, nausea, shortness of breath, drowsiness, and listlessness. The health care provider is notified if these signs occur. Abdominal cramping is a side effect, not an adverse effect, of the parenteral form of the medication. A runny or stuffy nose is a side effect, not an adverse effect, of the medication.

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate by way of the nasal route. For which occurrence does the nurse tell the client to contact the health care provider? Abdominal cramps Stuffy or runny nose Headache and nausea Decreased urine output

Weight loss Projectile vomiting Distended upper abdomen Rationale: HPS occurs when the circular muscle of the pylorus becomes thickened, causing constriction of the pylorus and obstruction of the gastric outlet. Clinical manifestations include projectile vomiting, a hungry infant who eagerly accepts a second feeding after the vomiting episode, weight loss, signs of dehydration, and a distended upper abdomen. A readily palpable olive-shaped mass in the epigastrium just to the right of the umbilicus is noted, and gastric peristaltic waves, moving from left to right across the epigastrium, are visible. Laboratory findings include metabolic alkalosis, a result of the vomiting that occurs in this disorder. Facial edema and metabolic acidosis do not occur in this disorder.

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply. Weight loss Facial edema Metabolic acidosis Projectile vomiting Distended upper abdomen

Contact the health care provider Rationale: The optimal therapeutic serum level for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A digoxin concentration greater than this level indicates toxicity, and requires the nurse to contact the health care provider. The remaining options are inappropriate because they could delay necessary and immediate intervention, resulting in harm to the client.

A nurse preparing to administer digoxin to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.0 ng/mL (2.6 nmol/L). On the basis of this result, the nurse would: Administer the digoxin Contact the health care provider Wait for the health care provider to make rounds and report the result Check the client's apical heart rate and administer the digoxin if the rate is faster than 60 beats/min

Cheeseburger Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness.

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions? Coffee Broccoli Cheeseburger Chocolate milk

Vitamin C Rationale: Dietary therapy for the client with osteoporosis includes foods high in calcium. If a fracture has occurred, the nurse encourages the client to eat foods high in vitamin C, protein, and iron, because these nutrients will promote healing. Although fats and carbohydrates should be included in the daily diet, they are not specifically related to the healing process. Foods containing concentrated sugar do not promote healing.

A nurse provides dietary instructions about foods that will promote healing to a client diagnosed with osteoporosis who has sustained a fracture. The nurse tells the client that it is best to consume foods that are high in: Fats Vitamin C Carbohydrates Concentrated sugar

Contact the health care provider if the skin appears yellow Rationale: Fluorescein angiography provides a detailed image and permanent record of eye circulation. Photographs are taken in rapid succession after the intravenous administration of dye. After the test, the client may feel weak and nauseated. Once the nausea has resolved, the client is encouraged to drink fluids to eliminate the dye. The nurse also encourages rest and emphasizes that any yellow discoloration of the skin will disappear in a few hours. After the test, the urine will be bright green until the dye has been excreted. The client is instructed to avoid direct sunlight until pupil dilation returns to normal.

A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must: Drink fluids to eliminate the dye Contact the health care provider if the skin appears yellow Expect that the urine will be bright green until the dye has been excreted Wear sunglasses and avoid direct sunlight until pupil dilation returns to normal

Urine output must be measured and that the health care provider should be notified if output is less than 500 mL in a 24-hour period Rationale: Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg, proteinuria is no more than 500 mg/day (trace to 1+), and symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet should provide ample protein and calories, and fluid and sodium should not be limited. The disease is considered severe when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours). Therefore, urine output of less than 500 mL/24 hr should prompt the client to notify the health care provider.

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: Sodium intake is restricted Fluid intake must be limited to 1 quart (1 litres) each day Urine output must be measured and that the health care provider should be notified if output is less than 500 mL in a 24-hour period Urinary protein must be measured and that the health care provider should be notified if the results indicate a trace amount of protein

"I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "I need to come back the clinic to have my lithium blood level checked." "I should drink 2 to 3 quarts (1.9 to 2.8 litres) of liquid every day." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

Positive result on d-dimer study Rationale: DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased. The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Increased platelet count Shortened prothrombin time Positive result on d-dimer study Decreased fibrin-degradation products

Flulike pulmonary symptoms Rationale: Histoplasmosis is a fungal infection of the lungs. The client typically experiences a flulike pulmonary illness with cough, chest pain, dyspnea, headache, fever, arthralgia, anorexia, erythema nodosum, hepatomegaly, and splenomegaly. Neurological disturbances, gastrointestinal disturbances, and cardiac dysrhythmias are not associated with this infection.

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? Neurological deficits Cardiac dysrhythmias Gastrointestinal disturbances Flulike pulmonary symptoms

Check the uterus and amount of lochia discharge Rationale: After delivery, the normal heart rate ranges from 60 to 90 beats/min. Tachycardia may indicate excitement, fatigue, dehydration, hypovolemia, pain, or infection. If tachycardia is noted, additional assessments — blood pressure, location and firmness of the uterus, amount of lochia, estimated blood loss at delivery, and hemoglobin and hematocrit determinations — should be carried out. Although the nurse would document the findings, it is most appropriate for the nurse to assess the client to determine the cause of the tachycardia. Oral fluids are important if the client is dehydrated, but further assessment of the problem is required and dehydration would first need to be confirmed. Rechecking the heart rate in 1 hour will delay necessary interventions.

A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first: Document the findings Offer the client oral fluids Recheck the heart rate in 1 hour Check the uterus and amount of lochia discharge

Hunger Weakness Blurred vision Rationale: The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia. Symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations.

A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. Hunger Weakness Blurred vision Increased thirst Increased urine output

Every morning before breakfast, with a full glass of water Rationale: Alendronate is a medication used to treat postmenopausal osteoporesis, glucocorticoid-induced osteoporosis, and Paget's disease of bone. Proper administration is necessary to maximize bioavailability and minimize the risk of esophagitis. The medication should be taken in the morning before breakfast on an empty stomach to maximize its bioavailability. No food, including orange juice or coffee, should be consumed for at least 30 minutes after alendronate is taken. To minimize the risk of esophagitis, the client should take the medication with a full glass of water and remain upright (seated or standing) for at least 30 minutes. Therefore taking the medication at bedtime, with orange juice to help with absorption, and every morning after breakfast, followed by a 30-minute period of lying down, are all incorrect.

Alendronate is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? At bedtime With orange juice, to enhance absorption at night Every morning before breakfast, with a full glass of water Every morning after breakfast, after which the client should lie down for 30 minutes

Nausea Eye pain Vomiting Headache Rationale: In acute closed-angle glaucoma, the onset of symptoms is acute and the client complains of sudden excruciating pain around the eyes that radiates over the sensory distribution of the fifth cranial nerve. Headache or brow ache, nausea, vomiting, and abdominal discomfort may also occur. Other symptoms of glaucoma include seeing colored halos around lights, sudden blurred vision with decreased light perception, and loss of peripheral vision.

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which characteristic of the disorder does the nurse expect the client to exhibit? Select all that apply. Nausea Eye pain Vomiting Headache Diminished central vision Increased light perception

Ensuring that direct pressure is applied to the external hemorrhage site Ensuring a patent airway and supplying oxygen to the client as prescribed Inserting an intravenous (IV) catheter and administering fluids as prescribed Rationale: When caring for a client in hypovolemic shock, the nurse must first ensure a patent airway and supply oxygen to the client. The nurse would insert an IV catheter if one is not already present and administer fluids as prescribed. The nurse would elevate the client's feet, keeping his or her head flat or elevated to a 30-degree angle. Direct pressure is applied to the site of external bleeding. The nurse would take the client's vital signs every 5 minutes until they were stable. The nurse would not leave the client alone.

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply. Maintaining the client in a high Fowler's position Checking the client's vital signs every hour until stable Ensuring that direct pressure is applied to the external hemorrhage site Ensuring a patent airway and supplying oxygen to the client as prescribed Inserting an intravenous (IV) catheter and administering fluids as prescribed Ensuring that the call bell is in place for the client's use when the nurse is out of the room

Increased white blood cell (WBC) count Rationale: Sickle cell disease is a genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. The main laboratory finding associated with sickle cell disease is the large percentage of HbS present on electrophoresis. The reticulocyte count is increased, indicating anemia of long duration, and the total bilirubin level is increased. The hematocrit level is low and decreases during crisis, because the bone marrow fails to produce cells during stressful periods. The WBC count is usually higher than normal in clients with sickle cell disease. It is believed that this increase is related to chronic inflammation resulting from tissue hypoxia and ischemia.

Laboratory studies are performed on a client diagnosed with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? Low reticulocyte count Low total bilirubin level Increased hematocrit count Increased white blood cell (WBC) count

Assessing the wound Rationale: View video. When performing a dressing change, the nurse dons clean gloves and removes the old dressing; checks the dressing for drainage, noting the amount, color, and odor if drainage is present; and discards the gloves and dressing. The nurse next assesses the wound for size, redness, swelling, and amount, color, odor, and type of drainage, if drainage is present. Next the nurse washes the hands and sets up the sterile field; dons sterile gloves; cleanses the wound with solution as prescribed, moving from the least to the most contaminated area; and redresses the wound. If a drain is present, the nurse applies additional layers of gauze as needed.

The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next? Assessing the wound Donning sterile gloves Cleansing the wound Setting up the sterile field

An increase in muscle strength Rationale: Myasthenia gravis is a disease that affects the myoneural junction. It is believed to result from an autoimmune response that destroys a variable number of acetylcholine receptors at the myoneural junction. A positive result on Tensilon testing is considered diagnostic. In this test, edrophonium (Tensilon), a short-acting anticholinesterase, is administered intravenously. A client with myasthenia gravis experiences a brief but significant increase in muscle strength in previously weakened muscles in response to the medication, and this response is considered a positive result. A decrease or a lack of change in muscle strength could indicate a cholinergic crisis. The presence of tremors in previously weakened muscles is unrelated to this test.

A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result? A decrease in muscle strength No change in muscle strength An increase in muscle strength The presence of tremors in previously weakened muscles

Palpating the abdomen Rationale: Wilms' tumor, or nephroblastoma, is the most common renal tumor in children. Arising from the renal parenchyma of the kidney, this tumor grows very rapidly. It may be unilateral and localized or bilateral and sometimes involves metastasis to other organs. The tumor mass should not be palpated because of the risk that the protective capsule will rupture. Excessive manipulation can result in seeding of the tumor and the spread of cancerous cells. The nurse would place a sign on the bed warning against palpation of the child's abdomen. Taking temperatures rectally, turning the child to the right side, and measuring blood pressure in the right arm are interventions that do not need to be avoided.

A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid: Palpating the abdomen Taking temperatures rectally Turning the child to the right side Measuring blood pressure in the right arm

CO2 and pH both indicate alkalinity

In respiratory alkalosis, CO2 and pH will reflect what? (alkalinity, acidosis)

Sore throat Rationale: Graves disease (hyperthyroidism) occurs as a result of excessive thyroid hormone secretion. Propylthiouracil is an antithyroid medication that blocks thyroid hormone production. One adverse effect is agranulocytosis, and the client is instructed to report signs of infection such as a sore throat. Fatigue may or may not occur in this disorder; however, it is not an adverse effect of the medication. One manifestation of Graves disease is heat intolerance, and the client may experience diaphoresis even when the environmental temperature is comfortable for others.

Propylthiouracil has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which occurrence does the nurse tell the client to contact the health care provider? Fatigue Diaphoresis Sore throat Heat intolerance

Thyroid-stimulating hormone (TSH) Rationale: Somatropin is a growth hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is assessed before treatment and periodically thereafter. Creatinine and BUN are used to evaluate renal function, and hemoglobin reflects hematologic activity.

A child with growth hormone deficiency will be receiving somatropin. The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? Creatinine Hemoglobin Blood urea nitrogen (BUN) Thyroid-stimulating hormone (TSH)

Hearing loss

A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client? Nausea Bloody urine Hearing loss Electrocardiographic changes

boiled rice

A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child: Boiled rice Cooked pasta Warm oatmeal Baked macaroni and cheese

Fever Vasculitis Abdominal pain

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. Fever Vasculitis Weight gain Increased energy Abdominal pain

Spinach Legumes Whole grains

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. Bananas Potatoes Spinach Legumes Whole grains Milk products

Bounding, full peripheral pulses Rationale: The normal total serum calcium level ranges from 8.6-10.2 mg/dL (2.15-2.55 mmol/L). Hypercalcemia occurs when the total serum calcium level exceeds 10 mg/dL (2.5 mmol/L). Some of the key features of hypercalcemia are increased heart rate and blood pressure; bounding, full peripheral pulses; ineffective respiratory movement related to profound skeletal muscle weakness; disorientation; diminution or absence of deep tendon reflexes; increased urine output; and hypoactive bowel sounds.

A nurse reviews the results of a total serum calcium determination in a client with chronic kidney disease. The results indicate a level of 12.0 mg/dL (3 mmol/L). In light of this result, which finding does the nurse expect to note during assessment? Decreased urine output Hyperactive bowel sounds Bounding, full peripheral pulses Hyperactive deep tendon reflexes

Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short Rationale: A cerebral aneurysm is a thin-walled outpouching or dilation of an artery of the brain. When an aneurysm ruptures, bleeding into the subarachnoid space usually ensues. Aneurysm precautions are implemented to maintain a stable perfusion pressure and help prevent rupture. The client is placed in a quiet private room without a telephone. The room is kept slightly darkened, and bright lighting is avoided. Stool softeners are administered to help keep the client from straining during defecation. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and significant others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. Isometric exercises and use of the Valsalva maneuver are avoided because both increase intrathoracic and intraabdominal pressure. Bed rest with the head of the bed elevated 30 degrees may be prescribed. Some health care providers permit bathroom privileges for selected clients. If the client is allowed out of bed, the nurse stresses the importance of not bending over.

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. Keeping the room slightly darkened Placing the client in a room with a quiet roommate Encouraging isometric exercises if bed rest is prescribed Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short

"Does your child have an allergy to peanuts?" Rationale: Dimercaprol may be used in conjunction with EDTA to treat lead poisoning. Dimercaprol is administered by way of deep intramuscular injection. Calcium disodium edetate is administered by way of the intravenous or intramuscular route. Dimercaprol must not be used in the presence of a glucose-6-phosphate dehydrogenase deficiency (G6PD) or peanut allergy, nor should it be given in conjunction with iron. Therefore the nurse must ask about allergy to peanuts. The assessment questions noted in the remaining options are unrelated to the administration of this medication

Calcium disodium edetate and dimercaprol is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications? "Can your child swallow pills?" "Has your child been running a fever?" "Does your child have an allergy to peanuts?" "How long has your child been exposed to the lead?

Levothyroxine amplifies the effect of warfarin sodium Rationale: Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin sodium are enhanced. If warfarin sodium administration is instituted in a client who takes levothyroxine, the dose of warfarin sodium should be reduced. Warfarin sodium is not contraindicated in the client who is using levothyroxine. Concurrent administration does not cause an allergic reaction.

Warfarin sodium is prescribed for a hospitalized client. While transcribing the health care provider's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the health care provider to confirm the prescription for warfarin sodium because: Warfarin sodium amplifies the effect of levothyroxine Levothyroxine amplifies the effect of warfarin sodium Warfarin sodium is contraindicated with the use of levothyroxine A severe allergic reaction may occur if warfarin sodium is administered concurrently with levothyroxine

Helping the woman empty her bladder Rationale: In the postpartum period, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is found to be higher than the expected level or shifted from the midline position (usually to the right), the bladder may be distended. The location of the fundus should be rechecked after the woman has emptied her bladder. If the fundus is difficult to locate or is boggy (soft), the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Encouraging the woman to walk is inappropriate at this time. The nurse would document fundal position, consistency, and height and any other interventions taken (e.g., uterine massage) after the woman has emptied her bladder.

nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: Documenting the findings Encouraging the woman to walk Helping the woman empty her bladder Massaging the fundus gently until it becomes firm

Epistaxis Rationale: Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism (i.e., conversion of plasminogen to plasmin, which destroys the fibrin in the blood clot). The thrombus, or blood clot, disintegrates when a thrombolytic medication is administered within 4 hours of an AMI. Necrosis resulting from blockage of the artery is prevented or minimized, and hospitalization may be shortened. Bleeding, a major adverse effect of thrombolytic therapy, may be superficial or internal and may be spontaneous. Epigastric pain, vomiting, and diarrhea are not adverse effects of this therapy.

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client? Diarrhea Vomiting Epistaxis Epigastric pain

Lie down to administer the subcutaneous injection

A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium at home. The nurse teaches the client about the medication and tells the client to: Store the medication in the refrigerator Lie down to administer the subcutaneous injection Inject the medication in the upper outer aspect of the arm Discard the medication if the solution appears pale yellow

Spinach Rationale: Oral calcium salts are used to treat mild hypocalcemia and to supplement dietary calcium. The client is instructed to take oral calcium with a large glass of water with or after a meal to promote absorption. The client is also instructed to avoid taking calcium with foods that can suppress calcium absorption. Such foods include spinach, Swiss chard, beets, bran, and whole-wheat cereals. The client does not need to avoid fish, milk, or watermelon.

Calcium carbonate is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication? Fish Milk Spinach Watermelon

Maintaining the client on bed rest for 3 hours Rationale: Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Excessive hypotension (first-dose syncope) may occur in the client with heart failure or in the client who is severely salt or volume depleted. The client is closely monitored for hypotension at the start of therapy and is maintained on bed rest for 3 hours after the initial dose. Checking the apical heart rate will provide information about the client's cardiac status but is not an intervention specifically related to this medication. Increased urine output and decreased wheezing are expected if the client has received a diuretic.

Captopril is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose? Checking the client's apical heart rate Maintaining the client on bed rest for 3 hours Monitoring the client for increased urine output Checking the client's breath sounds for decreased wheezing

"I need to stop the medication and call my doctor if I have severe diarrhea." Rationale: Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should maintain a high fluid intake (eight to ten 8-oz [235 ml] glasses of fluid per day) while taking the medication. The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose.

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? "I need to limit my intake of fluids while I'm taking this medication." "I need to stop the medication and call my doctor if I have severe diarrhea." "I can expect skin redness and a rash when I take this medication." "I may get a burning feeling in my throat, but it's normal and will go away."

Intake and output Rationale: Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone. Desmopressin promotes renal conservation of water. The hormone accomplishes this by acting on the collecting ducts of the kidney to increase their permeability to water, resulting in increased water reabsorption. The client is instructed to monitor and record daily intake and output of fluid. If the dose prescribed is adequate, urine volume should rapidly drop to normal. Appetite, pulse rate, and changes in bowel pattern are not associated with the use of this medication.

Desmopressin is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while taking the medication? Appetite Pulse rate Bowel pattern Intake and output

scrambled eggs

Ferrous sulfate is prescribed for a client. The nurse tells the client that it is best to take the medication with: Milk Water Any meal Scrambled eggs

Checking the client's blood pressure Rationale: Methylergonovine is an oxytocic that stimulates contraction of the uterus and causes arterial vasoconstriction. It is used for the prevention and treatment of postpartum and postabortal hemorrhage caused by uterine atony or subinvolution. Because the medication causes arterial vasoconstriction and hypertension, the nurse checks the client's blood pressure before administering the medication. There is no information to indicate that the client has had an episiotomy. Although the nurse may palpate the client's bladder, this action is unrelated to the use of the medication.

Methylergonovine is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication? Checking the episiotomy site Palpating the client's bladder Checking the client's blood pressure Ensuring that the uterus is contracted

Lithium carbonate Rationale: Glyburide is a hypoglycemic medication. If the client takes a corticosteroid, thiazide diuretic, or lithium carbonate concurrently, the effect of the glyburide is diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral hypoglycemic.

Although previously well controlled with glyburide, a client's fasting blood glucose has been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? Atenolol Phenelzine Allopurinol Lithium carbonate

350 Rationale: When calculating how to distribute fluid to a client under fluid restriction, the nurse usually allows half of the allotted total oral fluids between 7 a.m. and 3 p.m., the period during which the client is more active, consumes two meals, and takes most of oral medications. Another two fifths is allotted to the evening shift, and the balance is allowed during the night.

An adult client with chronic kidney disease who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?

Uteroplacental insufficiency during a contraction Rationale: The observation that the has nurse noted in this tracing is late decelerations. Late decelerations constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly associated with a contraction. Early decelerations result from pressure on the fetal head during a contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability refers to the difference between successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly.

Late decelerations indicate: Umbilical cord compression Pressure on the fetal head during a contraction Uteroplacental insufficiency during a contraction Inadequate pacemaker activity of the fetal heart