GI medications

mucosal barrier enhancer

reduce the effect of acid secretion, promote healing. (sucralfate)

sweating and pallor

the nurse is monitoring a client for the early signs and symptoms of dumping syndrome. which finidings indicate this occurrence?

one hour before meals and at bedtime

a client with a gastric ulcer has a prescription for sacralfate 1 gram by mouth 4 times daily. the nurse should schedule the medication for which times.

cerebral vasospasm

a narrowing of arteries adjacent to the aneurysm that results in ischemia and infarction of brain tissue if it progresses

neomycin and metronidazole

_____ and ____ are second-line treatments for hepatic encephalopathy

nighttime ( nocturnal) enuresis is usually outgrown without therapeutic interventions

a 7 year old child is seen in a clinic, and the pediatrician documents a diagnosis of nighttime (nocturnal) enuresis. the nurse should provide which information to the parents?

providing a quiet atmosphere with dimmed lighting

a child is diagnosed with Reye's syndrome. the nurse creates a nursing care plan for the child and should include which intervention in the plan?

trauma to the bladder or abdomen

a client arrives at the emergency department with complaints of low abdominal pain. and hematuria. the client is afebrile. the nurse next assess that client to determine a history of which condition?

tender, indurated prostate gland that is warm to the touch

a client complain of fever, perineal pain, and urinary urgency, frequency, and dysuria. to assess whether the clients problem is related to bacterial prostatitis, the nurses reviews the results of the prostate examination for which characteristic of this disorder?

this is a normal, expected event

a client had a new colostomy created 2 days earlier and is bringing to pass malodorous flatus from the stoma. what is the correct interpretation by the nurse?

affect is flat, with periods of emotional lability

a client has a neurological deficit involving the liming system. on assessment, which finding is specific to this type of deficit?

vomiting following cancer chemotherapy

a client has a new prescription for metoclopramide. on review of the chart, the nurse identifies that this medication can be safely administered with which condition?

an episode of diarrhea

a client has an as needed prescription for loperamide hydrochloride. for which condition should the nurse administer this medication.

an episode of diarrhea

a client has an as needed prescription for loperamide hydrochloride. for which condition should the nurse administer this medication?

nausea and vomiting

a client has an as needed prescription for ondansetron. for which conditions should the nurse administer this medication

nausea and vomiting

a client has an as-needed prescription for ondansetron. for which conditions should the nurse administer this medication?

heart burn

a client has been taking omeprazole for 4 weeks. the ambulatory care nurse evaluates that the cilent is receiving the optimal intended effect of the mediation if the cleint reports the absence of which symptom?

heart burn

a client has been taking omeprazole for 4 weeks. the ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

reduction of steatorrhea

a client has begun medication therapy with pancrelipase. the nurse evaluates that the medication is having the optimal intended benefit if which effect is observed.

reduction of steatorrhea

a client has begun medication therapy with pancrelipase. the nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

fluid separates into concentric rings and test positive for glucose

a client has clear fluid leaking from the nose following a basilar skull fracture. which finding would alert the nurse that cerebrospinal fluid is present?

malaise

a client has developed hepatitis A after eating contaminated oysters. the nurse assess the client for which expected assessment finding?

administer stool softeners as prescribed encourage a high fiber diet to promoted bowel movements without straining

a client has just had a hemorrhoidectomy. which nursing interventions are appropriate for this client?

fluid and electrolyte imbalance

a client has just had surgery to create an ileostomy. the nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

assessing for the return of the gag reflex

a client has undergone esophagogastroduodenoscopy. the nurse should place highest priority on which item as part of the clients care plan?

increase intake of fluids, including juices

a client i diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food". what instruction should the nurse give the client to provide adequate nutrition?

iv fluids containing dextrose

a client is admitted to a hospital with a diagnosis of DKA . the initial blood glucose level is 950. a continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. the serum glucose level is now decreased to 240. the nurse would next prepare to administer which medication?

maintain a patent airway

a client is admitted to an emergency department, and a diagnosis of myxedema coma is made. which action should the nurse prepare to carry out initially?

notify the PHCP before performing the catheterization

a client is admitted to the emergency department following a fall from a horse, and the primary health care provider (PHCP) prescribes insertion of a urinary catheter. while preparing fro the procedure, the nurse notes blood at the urinary meatus. the nurse should take which action?

blood pressure, 100/50mmHg, pulse 130,

a client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. four house after surgery, the nurse takes the client's vitals and empties the urinary drainage bag. which assessment finding indicates the need to notify the primary health care provider

gray-blue color at the flank abd guarding and tenderness left upper quadrant pain with radiation to the back

a client is admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. which assessment findings would be consistent with acute pancreatitis? select all that apply

intravenous infusion of normal saline

a client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. the nurse would immediately prepare to initiate which anticipated primary health care provider's prescription?

slurred speech

a client is taking the prescribed dose of phenytoin to control seizures. results of a phenytoin blood level study reveal a level of 35 mcg/ml. which findings would be expected as a result of this lab result.

exhaling during repositioning

a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

decongestants

a client who has a cold is seen in the emergency department with an inability to void. because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which mediation?

relief of epigastric pain

a client who has uses NSAIDS has been taking misoprostol. the nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?

relief of epigastric pain

a client who uses non steroidal anti-inflammatory drugs ( NSAIDS) has been taking misoprostol. the nurse determines that the misoprostol is having the intended therapeutic effect if which findings is noted?

prednisone

a client with DM visits the health care clinic. the clients DM previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180-200. which medication, if added to the clients regimen, may have contributed to the hyperglycemia?

providing information, giving positive feedback, and encouraging relaxation

a client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?

infusing slowly over 60 minutes

a client with a UTI is receiving ciprofloxacin via IV. the nurse appropriately administers the medication by performing which action?

comatose state deep, rapid breathing elevated blood glucose level

a client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. which findings support this diagnosis?

one hour before meals and at bedtime

a client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. the nurse should schedule with medication for which times?

the medications will kill the bacteria and stop the acid production

a client with a peptic ulcer is diagnosed with a H pylori infection. the nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole and amoxicillin. which statement by the client indicates the best understanding of the medication regimen?

the medications will kill the bacteria ands to the acid production

a client with a peptic ulcer is diagnosed with a H pylori infection. the nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, amoxicillin. which statement by the client indicates the best understanding of the medication regimen?

keeping the linens wrinkle-free under the client preventing unnecessary pressure on the lower limbs turning and repositioning the client at least every 2 hours.

a client with a spinal cord injury is prone to experiencing autonomic dysreflexia. the nurse should include which measures in the plan of care to minimize the risk of occurrence?

place the client on a cardiac monitor notify the primary health care provider review the clients mediations to determine whether any contain or retain potassium

a client with acute kidney injury has a serum potassium level of 7.0 mEq/L. the nurse should plan which actions as a priority?

heamatocrit of 33%

a client with chronic kidney disease is receiving epoetin alfa. which laboratory result would indicate a therapeutic effect of the medication?

notify the primary health care provider

a client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. on assessment, the nurse notes that the clients temperature is (102f) which nursing actions is most appropriate?

administer oxygen to the client notify the primary health care provider and rapid response team stop dialysis, and turn the client on the left side with head lower than the feet

a client with chronic kidney diseases being hemodialyzed suddenly becomes short of breath and complains of chest pain. the client is tachycardia, pale, and anxious, and the nurse suspects air embolism. what are the priority nursing actions?

checking the frequency and consistency of bowel movements

a client with chrons disease is scheduled to receive an infusion of infliximab. what intervention by the nurse will determine the effectiveness of treatment

checking the frequency and consistency of bowel movements

a client with crohn's disease is scheduled to receive an infusion of infliximab. what intervention by the nurse will determine the effectiveness of treatment?

convey empathy, trust, and respect toward the client

a client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. what is the appropriate intervention to decrease the clients anxiety.

hypoglycemia may be experienced before dinnertime the insulin should be administered at room temperature

a client with diabetes mellitus is taking humulinNPH inulin and regular insulin every morning. the nurse should provide which instructions to the client?

lying recumbent following meals

a client with hiatal hernia chronically experiences heartburn following meals. the nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?

a temporary worsening of the condition

a client with myasthenia graves has become increasingly waker the primary health care provider prepares to identify whether the client is reacting to an over dose of the medication (cholinergic crisis) or an increasing severity of the disease ( myasthenia crisis). an injection of edrophonium is administered. which findings would indicate that the client is in cholinergic crisis?

insertion of a nephrostomy tube placement of a ureteral stent with ureteroscopy

a client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. the nurse anticipates which treatment will be done to relieve the obstruction?

WBC count 3,000

a client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. which value indicates that the client is experiencing an adverse effect to the medication.

direct bilirubin level of 2 mg/dl

a client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. which laboratory value would indicate toxicity associated with the medication?

the best time for me to exercise is afterbreakfast

a client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

pallor. diminished pulse, and pain in the left hand

a hemodialyiis client with a left arm fistula is at risk for arterial steal syndrome. the nurse should assess for which manifestations of this complications?

cloudy CSF, elevated protein, and decreased glucose levels

a lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. the nurse reviews the results would verify the diagnosis?

dysuria and penile discharge

a male client has a tentative diagnosis of urethritis. the nurse should assess the client for which manifestation of the disorder?

bradycardia

a mother arrives at the emergency department with her 5-year old child and states that the child fell off a bunk bed. a head injury is suspect. the nurse checks the child's airway status and assess the child's airway status and assess the child for early and late signs of increased ICP. which is a late sign of increased ICP?

increased immunosuppression therapy

a week after kidney transplantation, a client develops a temperature of 101F, the blood pressure is elevated, and there is tenderness over the transplanted kidney. the serum creatinine is rising and urine output is decreased. the X-ray indicates that the transplanted kidney is enlarged. based on these assessment findings, the nurse anticipates which treatment?

laxatives bulk forming

absorb water into the feces and increase bulk to produce large and soft stools contraindicated in bowel obstruction dependency can occur with long term use side and adverse effects include gastrointestinal disturbances, dehydration, and electrolyte imbalances

Methylprednislone (Solu-medrol)

an adjunct for SCI management within first 8 hours of injury improves blood flow to injury site, facilitating tissue repair

medication regimes to treat h. pylori

an antibacterial agen alone is not effective for eradicating ______, because the bacterium readily becomes resistant to the agent. triple or quadruple therapy with a variety of medication combinations is used. ( two antibiotics and a PPI)

it administers a small continuous does of short-duration insulin subcutaneously. the client can self-administer an additional bolus dose from the pump before each meal.

an external insulin pump is prescribed for a client with diabetes mellitus. when the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?

reposition the infant frequently

an infant with a diagnosis of hydrocephalus is scheduled for surgery. which is the priority nursing intervention in the preoperative period?

confusion

an older client recently has been taking cimetidine. the nurse monitors the client for which most frequent central nervous system side effect of this medication?

osmotics

attract water int the large intestine to produce bulk and stimulate peristalsis

urinary strictures

bethanechol chloride is prescribed for a client with urinary retention. which disorder would be a contraindication to the administration of this medication?

histamine blockers

block all factors that stimulate the parietal cells in the stomach to secrete hydrochloric acid

Nicardipine (Cardene)

calcium channel blocker vasodilatory effect that lowers BP monitor BP continuously

impaired voluntary movements

carbidopa-levodopa is prescribed for a client with parkinson's disease. the nurse monitors the client for side and adverse effects of the medication. which finding indicates that the client is experiencing an adverse effect.

phenytoin (dilantin)

depresses seizures activity by altering ion transport in motor cortex slow infusion rate if bradycardia, hypotension, cardiac dysrhythmias occur.

lorazepam ( ativan)

depresses subcortical areas of CNS anti-epileptic sedative- hypnotic anti anxiety

antacids

direct alkaline buffer to control the pH of the gastric mucosa (mag oxide, mag hydroxide, aluminum hydroxide, calcium carbonate)

a rigid, board-like abdomen

the nurse is monitoring a client with a diagnosis of peptic ulcer. which assessment finding would most likely indicate perforation of the ulcer?

duodenal

during pain occurs in the midepigastric area 1.5-3 hours after a meal and during the night ( often awakens the client) melena is more common than hematemesis pain is often relieved by the ingestion of food.

blood urea nitrogen level of 25mg/dl

following kidney transplantation, cyclosporine is prescribed for a client. which laboratory result would indicate an adverse effect from the nurse of this mediations?

red meats whole grains carbonated beverages

glimepiride is prescribed for a client with diabetes mellitus. the nurse instructs the client that which food items are most acceptable to consume while taking this medication?

gastric ulcers

gnawing, sharp pain in or to the left of the midepigastic region occurs 30- 60 minutes after a meal ( food ingestion accentuates the pain) hematemesis is more common than melena

emollients

inhibit absorption of water so fecal mass remains large and soft. used to avoid straining

proton pump inhibitorsq

inhibit gastric acid secretion by specific inhibition of the hydrogen-potassium-adensoine triphosphatase enzyme system. (-zoles)

gastric ulcer

involves ulceration of the mucosal lining that extends to the submucosal layers of the stomach. predisposing factors include stress, smoking, the use of corticosteroids, NSAIDs, alcohol, hx of gastritis, family hx, infection with H pylori

duodenal ulcers

is a break in the mucosa of the duodenum. risk factors and causes include infection with H pylori, alcohol intake, smoking, stress, caffeine, and the use of aspirin, corticosteroids, and NSAIDs complications include bleeding, perforation, gastric outlet obstruction, and intractable disease

peptic ulcer disease

is an ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus in portions accessible to gastric secretions; erosion may extend through the muscle.

antiemetics

medications used to control vomiting an emotion sickness the choice of the antiemetic is determined by the cause of the nausea and vomiting monitor vitals and intake and output and for signs of dehydration and fluid and electrolyte imbalances limit odors in the clients room when the client is nauseated or vomiting limit oral intake to clear liquids when the client is nauseated or vomiting

tremors drowsiness hypotension

meperidine has been prescribed for a client to treat pain. which side and adverse effects should the nurse monitor for?

the client is experiencing a pulmonary reaction requiring cessation of the medication

nitrofurantoin is prescribed for a client with a urinary tract infection. the client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. the nurse should make which interpretation about the clients complaints?

mannitol

osmotic diuretic pulls water from brain interstitial into plasma used to treat increased ICP needs neurological assessment every hour

restlessness

oxybutynin chloride is prescribed for a client with urge incontinence. which sign would indicate a possible toxic effect related to this medication?

urination is not painful

phenazopyridine is prescribed for a client with a urinary tract infection. the nurse evaluates that the medication is effective based on which observation?

antacids

react with gastric acid to produce neutral salts or salts of low acidity. inactivate pepsin and enhance mucosal protection but do not coat the ulcer crater these medications are used or peptic ulcer disease and gastroesophageal reflex disease they should be taken on a regular schedule, some are prescribed to be taken 1 and 3 hours after each meal and at bedtime they should be chewed thoroughly and followed with a glass of water or milk

proton pump inhibitors

suppress gastric acid secretion used to treat active ulcer disease, erosive esophagitis, and pathological hyper secretory conditions contraindicated in hypersensitivity common side effects include headache, diarrhea, abdominal pain, and nausea.

histamine ( H2) receptor antagonists

suppress secretion of gastric acid alleviate symptoms and heartburn and assist in preventing complications of peptic ulcer disease. prevent stress ulcers and reduce the recurrence of all ulcers promote healing in gastroesophageal reflex disease should be caution in clients with impaired renal or hepatic function

take the oral medication every 12 hours at the same times every day

tacrolimus is prescribed for a client who underwent a kidney transplant. which instruction should the nurse include when teaching the client about this medication?

i ate shell fish about 2 weeks ago at a local restaurant

the PCP has determined that a cline has contracted Hep A based on flu-like symptoms and jaundice. which statement made by the client supports this medical diagnosis?

withhold the medication and all the PCP, questioning the prescription for the client

the PCP prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. the nurse should plan to take which most appropriate intervention?

tinnitus

the client arrives at the ED complaining of back spasms. the client state, " I have been taking 2-3 aspirin every 4 hours for the last week, and it hasn't helped my back. since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation?

respiratory or gastrointestinal infection during the previous month

the client is admitted to the hospital with a diagnosis of Guillain-Baree syndrome. which past medical history finding makes the client most at risk for this disease

headache, deteriorating level of consciousness, and twitching

the client newly diagnosed with chronic kidney disease recently has begun hemodialysis. knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?

refrigerate the insulin

the home care nurse visits a client recently diagnosed with DM who is taking Humulin NPH insulin daily. the client asks the nurse how to store the unopened vials of insulin. the nurse should tell the client to take which action?

diarrhea may occur secondary to the metformin the repaglinide is not taken if a meal is skipped the repaglinide is taken 30 minutes before eating a simple sugar food item is carried and used to treat mild hypoglycemia episodes.

the home health care nurse is visiting a client who has recently diagnosed with type 2 diabetes mellitus. the client is prescribed repaglinide and metformin. the nurse should provide which instructions to the client?

there is the potential of decreased effectiveness of birth control

the home health nurse visits a client who is taking phenytoin for control for seizures. during the assessment, the nurse notes that the client is taking birth control pills. which information should the nurse include in the teaching plan?

i need to stop my insulin

the home health nurse visits a client with a diagnosis of type 1 DM. the client reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24hrs. which additional statement by the client indicates a need for further teaching

bacteriuria

the nurse collects a UA preoperatively from a child with epispadias who is scheduled for surgical repair. when analyzing the results of the urinalysis, which should the nurse most likely expect to note?

suctioning equipment and oxygen

the nurse creates a plan of care for a child at risk for tonic-clonic seizures. in the plan of care, the nurse identifies seizure precaution and documents that which items need to be placed at the child's bedside?

i will take the climetidine with my meals i'll know the medication is working if my diarrhea stops taking the cimetidine with an antacid will increase its effectiveness

the nurse determines the client needs further instruction on cimetidine if which statements were made?

hemodiaylis kidney transplant bilateral nephrectomy

the nurse discusses plans for further treatment options with a client with symptomatic polycystic kidney disease. which treatment should be included in this discussion

i wil drive only during the daytime

the nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. which statement indicates that the client needs further clarification of the instructions?

this medication should only be taken with water

the nurse has given instructions to a client who has just been prescribed cholestyramine. with statement by the client indicates a need for further instruction

good oral hygiene is needed, including brushing and flossing

the nurse has given medication instructions to a client receiving phenytoin. which statement indicates that the client has an adequate understanding of the instructions?

ill try to eat my food either very warm or very cold

the nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. the nurse determines that the client needs further teaching if the client makes which statement?

we need to remind him to turn his head to scan the lost visual field

the nurse has instructed the family of a client with stroke "brain attack" who has homonymous hemianopsia about measures to help the client over come the deficit. which statement suggests that the family understands the measures to use when caring for the client?

im glad i don't have to lie still for this procedure

the nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. the nurse determines that the client needs further information if the client makes which statement?

electrocardiographic monitoring electrodes and intubation tray

the nurse is admitted a client with guillain- barre syndrome to the nursing unit. the client has complaints of inability to move both legs and resorts a tingling sensation above the waistline. knowing the complications of the disorder, the nurse should bring which most essential items into the clients room?

initiate an infusion of 3% NaCl restrict fluid to 800ml over 24 hours administer a vasopressin antagonist as prescribed

the nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118. which PCP prescriptions should the nurse anticipate receiving?

document the findings

the nurse is assessing a client 24 hours following a cholecystectomy. the nurse notes that the T-tube has drained 750ml of green-brown drainage since the surgery. which nursing intervention is most appropriate?

fever complaints of indigestion pain in the upper right quadrant after a fatty meal

the nurse is assessing a client who is experiencing an acute episode of cholecystitis. which of these clinical manifestations support this diagnosis?

fever, nausea, vomiting, and painful scrotal edema

the nurse is assessing a client with epididymitits. the nurse anticipates which finding on physical examination?

consistently uses adaptive equipment in dressing self

the nurse is assessing the adaptation of a client to changes in functional status after a stroke ( brain attack). which observation indicates to the nurse that the client is adapting most successfully?

nailed pressure

the nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. the nurse should use which technique to test the clients peripheral response to pain?

palpation of a thrill over the fistula

the nurse is assessing the patency of a clients left arm arteriovenous fistula prior to initiating hemodialysis. which finding indicates that the fistula is patent?

a client is aphasic the client has weakness on the right side of the body the client has weakness on the right side of the face and tongue.

the nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke ( brain attack). which characteristics are associated with this condition?

Nasotracheal suction as needed

the nurse is assigned to care for an 8 year old child with a diagnosis of a basilar skull fracture. the nurse reviews the pediatrician's prescriptions and should contact the pediatrician to question which prescription?

administer short-duration insulin intravenously

the nurse is caring for a client admitted to the emergency department with DKA. in the acute phase, the nurse plans for which priority intervention?

test the drainage for glucose

the nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the clients nostril. the nurse should take which initial action?

irrigating the nasogastric tube

the nurse is caring for a client following a gastrojejunostomy (billroth II procedure). which postoperative prescription should the nurse question and verify?

acetylcysteine

the nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. the client has been taking acetaminophen, and acetaminophen overdose is suspected. which antidote should the nurse prepare for administration if prescribed.

loosening restrivite clothing removing the pillow and raising padded side rails. positioning the client to the side, if possible, with the head flexed forward

the nurse is caring for a client who beings to experience seizures activity while in bed. which actions should the nurse take

monitor bowel activity

the nurse is caring for a client with chronic back pain. codeine has been prescribed for the client. specific to this medication, which intervention should the nurse include int he plan of care while the client is taking this medication.

cover the bladder with a nonadherteing plastic wrap

the nurse is caring for an infant with a diagnosis of bladder exstrophy. to protect the exposed bladder tissue, the nurse should plan which intervention?

increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

the nurse is caring for the client with increased intracranial pressure as a result of head injury? the nurse would note which trend in vital signs if the intracranial pressure is rising?

decreased force in the stream of urine

the nurse is collecting data from a client. which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?

time the seizures stay with the child move furniture away from the child

the nurse is creating a plan of care for a child who is at risk for seizures. which interventions apply if the child has a seizures?

pain relieved by food intake

the nurse is doing an admission assessment on an client with a history of duodenal ulcer. to determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer?

flaccid paralysis

the nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. which obersvation indicates that spinal shock persists?

a positive brudzinskis sign

the nurse is evaluating the status of a client who had a craniotomy 3 days ago. which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

padding the side of rails of the bed placing an airway at the bedside placing oxygen and suction equipment at the bedside flushing the intravenous catheter to ensure that the site is patent

the nurse is instituting seizure precautions for a client who is being admitted from the emergency department. which measures should the nurse include in planning for the clients safety?

hyperglycemia

the nurse is instructing a client with diabetes mellitus about peritoneal dialysis. the nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

i don't need to use my walker to get to the bathroom

the nurse is instructing a client with parkinson's disease about preventing falls. which client statement reflects a need for further teaching?

notify PCP

the nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. the client begins to complain of increased abdominal pain and begins to vomit. on assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. which is the most appropriate nursing intervention?

polyuria

the nurse is monitoring a client newly diagnosed with DM for signs of complications. which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

check the level of the drainage bag reposition the client to her or his side place the client in good body alignment check the peritoneal dialysis system for kincks

the nurse is monitoring a client receiving peritoneal dialysis notes that the clients outflow is less than the inflow. which actions should the nurse take?

treamors irritability nervousness

the nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction?

generalized edema

the nurse is performing an admission assessment on a 2- year old child who has been diagnosed with nephrotic syndrome notes that which most common characteristics is associated with this syndrome?

pallor edema anorexia proteinuria

the nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. which assessment findings should the nurse expect to observe?

notify the PCP

the nurse is performing an assessment on a client wh has returned from the dialysis unit following hemodialysis. the client is complaining of headache and nausea and is extremely restless. which is the priority nursing action?

maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

the nurse is planning care for a child with acute bacterial meningitis. based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

restrict fluids as prescribed

the nurse is planning care for a child with hemolytic uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. the nurse should plan to implement which measures?

coffee chocolate peppermint fried chicken

the nurse is planning to teach a client with GERD about substances to avoid. which items should the nurse include on this list? select all that apply?

inadequate fluid volume

the nurse is preparing a plan of care for a client with DM who has hyperglycemia. the nurse places priority on which client problem?

purple discoloration of the stoma

the nurse is providing care for a client with a recent transfers colostomy. which observation requires immediate notification of the primary health care provider?

grapefruit juice

the nurse is providing dietary instructions to a client who has been prescribed cyclosporine. which food item should the nurse instruct the client to exclude from the diet?

limit the fluids taken with meals

the nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?

drink 8-10 glasses of water per day

the nurse is providing discharge instructions to a client receiving trimethoprim-sulgamethoxazole. which instruction should be included in the list?

i need to constantly watch for signs of low blood sugar

the nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes who has been prescribed metformin. which client statement indicates the need for further teaching?

i should increase the fiber in my diet

the nurse is providing discharge teaching for a client with newly diagnosed crohns disease about dietary measures to implement during exacerbation episodes. which statement made by the client indicates a need for further instruction?

elevated creatinine level

the nurse is reviewing a clients record and notes that the prior health care provider has documented that the client has chronic kidney disease. on review of the laboratory results, the nurse most likely would expect to note which finding?

circumcision has been delayed to save tissue for surgical repair

the nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. which statement by the parents indicates their understanding of the plan?

pasta with sauce

the nurse is reviewing the lab result for a client with cirrhosis and notes that the ammonia level is 85 mcg/dl. which dietary selection does the nurse suggest to the client?

fasting blood glucose of 200 mg/dl

the nurse is reviewing the laboratory results for a client receiving tacrolimus. with lab results would indicate to the nurse that the client is experiencing an adverse effect of the medication

maintain NPO status until gag reflex has returned encourage coughing and deep breathing give hydromorphine IV as prescribed for pain

the nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. which interventions would the nurse expect to be prescribed for the client?

rigid extension an pronation of the arms and legs

the nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. on assessment of the child, the nurse expects to note which characteristic of this type of posturing?

ask the client to extend the arms

the nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterisks. how should the nurse assess for its presence?

ask the client to extend the arms

the nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. how should the nurse assess for its presence?

withdraws the NPH insulin first

the nurse is teaching a client with DM how to mix regular insulin and NPH insulin in the same syringe. which action, if performed by the client, indicates the need for further teaching?

taking medication as scheduled

the nurse is teaching a client with myasthenia graves about the prevention of myasthenia and cholinergic crises. which client activity suggests that teaching is most effective?

meningitis

the nurse notes documentation that a child is exhibiting an inability to flew the leg when the thigh is flexed anteriorly at the hip. which condition does the nurse suspect?

temperature

the nurse performs a physical assessment on a client wit h type 2 DM. findings include a fasting blood glucose level of 70, temp 101, pulse 82, respirations of 20 breaths per minute, and bp of 118/68. which finding would be the priority concern to the nurse?

ill let him decide when to return to his play activities

the nurse provided discharge instructions to the parents of a 2 year old child who had an orhciopexy to correct cryptorchidism. which statement by the parents indicates the further need for instructions?

i needs to limit my intake of dietary fiber

the nurse provides instructions to a client about measures to treat IBS. which statement by he client indicates a need for further teaching.

i will notify my PCP if my blood glucose level is higher than 250

the nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. the nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?

continue taking the medication; the brown urine occurs and is not harmful

the nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin for a urinary tract infection. the nurse should make which appropriate response?

i noticed his urine was the color of cola lately

the nurse reviews the record of a child who is suspected to have glomerulonephritis. which statement by the child's parents should the nurse expect that is associated with this diagnosis?

shakiness palpitations lightheadedness

the nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. the client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? select all that apply

I should decrease my oral fluids when i start this medication i should report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin

the nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. which statements by the client indicate understanding

braydicardia

the nurse, who is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. the nurse should check the client for which sign of overdose?

a chronic disability characterized by impaired muscle movement and posture

the parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. the nurse responds by explaining that the imitations occur as a result of which pathophysiological process?

1 hr

to prevent interactions with other mediations and interference with the action of the other medications, allow _____ between antacid administration and the administration of other medications.

sore throat

trimethoprim-sulfamethoxale is prescribed for a client. the nurse should instruct the client to report which symptom if it develops during the course of this medication therapy?

has the child has a sore throat or a throat infection in the last few weeks?

which question should the nurse ask the parents of a child suspected of having glomerulonephritis?