LEARNING SYSTEM PN 3.0

Administer the medication into the client's abdomen - The heparin should be administered into the client's abdomen.

A nurse is administering subcutaneous heparin to a client who is at risk for DVT. Which of the following actions should the nurse take?

Delay systemic absorption of the anesthetic properties of lidocaine : The nurse should inform the client that the meds such as lidocaine are often administered in combo with a vasoconstrictor such as epinephrine. Epinephrine decreases local blood flow n delays systemic absorption of the anesthetic property of lidocaine

A nurse is assisting with a clients laceration repair in which the provider will use both lidocaine l and epinephrine. The nurse should inform the client that epinephrine will perform which of the following actions?

Nitroglycerine : The nurse should anticipate administering nitroglycerin to a client who has unstable angina. This med acts by relaxing or preventing spasms in the coronary arteries along with dilating the arteries, which increases oxygenation & blood flow

A nurse is assisting with the admission of a client who has unstable angina. Which of the following meds should be administered?

"I have noticed my urine is orange in color." - The nurse should identify that an adverse effect of rifampin can be red-orange colored urine, saliva, sweat n tears. The nurse should also inform the client that permanent staining of contact lenses can occur. However, this adverse effect is harmless. The client should inform the provider if urine becomes dark in color since this can be an indication of hepatoxicity.

A nurse is caring for a client who has TB and is taking rifampin. Which of the following statements should indicate to the nurse that the client is experiencing an adverse effect?

Maintain a low-stimulation environment : To minimize confusion and anxiety, the nurse should maintain a low-stimulation environment for a client who has dementia

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take?

"Restraining the client can increase confusion." : Restraining a confused client can worsen confusion. The nurse should use other methods to prevent wandering

A nurse is caring for a client who is confused and wanders at night. The nurse asks the charge nurse if the client can be placed in physical restraints at bedtime. Which of the following responses should the charge nurse provide?

Sodium 123 mEq/L : Low sodium levels can cause confusion and lead to seizures, coma, and death. Normal levels of sodium are 136 to 145.

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following lab values can cause confusion?

"It must be difficult for you not to know what the doctor will find." - The nurse is expressing empathy in order to acknowledge the clients feelings and encourage further communication.

A nurse is caring for a client who is scheduled for a biopsy of a mass in a testicle. The client asks, "Do you think the doctor will find cancer?" Which of the following responses should the nurse make?

Place the unwrapped newborn on the mother's bare chest: skin-to-skin contact will maintain the newborn's temperature and elicit instinctive newborn feeding behaviors

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?

Restricted dosage flexibility - The nurse should identify that a disadvantage of an inhaled glucocorticoid and a long-acting beta2-agonist being combined in that the dosages of these meds are fixed, so the dose cannot be adjusted.

A nurse is caring for a client with asthma who has been taking an inhaled glucocorticoid and long-acting beta2-agonist combination dry powdered inhaler for maintenance therapy. The nurse should identify that which of the following is a disadvantage of this medication?

An 80 year old client who has a fractured hip

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at greatest risk for a complication?

Visual disturbances : The nurse should recognize that nausea, vomiting, abdominal discomfort, fatigue & visual disturbances are common manifestations that can indicate digoxin toxicity.

A nurse is collecting data from a client who has HF and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity?

Loss of red or green color discrimination : Ethambutol is an antitubercular med that impairs ribonucleid acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the med

A nurse is collecting data from a client who has TB and a prescription for ethambutol. The nurse should inform the client that he is likely to develop which of the following alterations as an adverse effect?

Hypotension : Nitroglycerin is a coronary vasodilator & antianginal agent. A major adverse effect of this med is hypotension; therefore blood pressure & pulse must be monitored before and after administration

A nurse is going administer a sublingual nitroglycerin tablet to a client who's reporting chest pain. Which of the following adverse effects should the nurse monitor?

Maternal HR > 120 - A client who is receiving terbutaline can experience tachycardia, which poses a significant risk to the mother. Therefore, when the maternal HR exceeds 120, the med should be stopped. Adverse effects results from activating beta1 receptors as well as beta2 receptors.

A nurse is monitoring a client who is receiving terbutaline to suppress preterm labor. Which of the following findings should indicate to the nurse that the client is experiencing an adverse effect of the medication?

"I have not had a BM today." : The nurse should identify that diphenoxylate-atropine is an opioid used to treat diarrhea. The therapeutic response of this med is a decrease in the frequency of watery stools due to reduced motility of the intestinal lining

A nurse is monitoring a client who received diphenoxylate-atropine. Which of the following statements by the client should indicate to the nurse that the medication has been effective?

Wrap the client's arm in a warm washcloth - Warmth helps increase the blood flow to the client's finger

A nurse is obtaining a capillary blood sample to determine the blood glucose level. The nurse prepares and punctures the client's finger for the procedure but doesn't obtain an adequate amount of blood. What should the nurse do?

Return blood to lab : Because the nurse knows that the delay will be more than a few minutes, she should return the unit of packed RBCs immediately to the lab, where the technician will maintain it at the appropriate temperature until the client is ready to receive it

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team can send someone in 30 min to initiate a new line. What should the nurse do?

"I will eat fruits & veggies that have a high potassium content everyday." - Hypokalemia is an adverse effect of diuretic therapy. Because the client is taking digoxin, the client will need to maintain a potassium level between 3.5 to 5.0 mg/dL to avoid digoxin toxicity.

A nurse is reinforcing discharge teaching with a client who has HF and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching?

Tertiary prevention : The nurse is providing tertiary prevention methods by offering stress management techniques to the abuser after the abuse has occurred. Tertiary prevention methods facilitate rehabilitative process for both victims of violence and those who perpetuate it.

A nurse is reinforcing teaching about stress management techniques with a parent who has admitted to verbally abusing her children. Which of the following strategies is the nurse providing?

Past cesarean delivery: Misoprostol is used for cervical ripening and induction of labor. It causes a higher incidence of uterine tachysystole. Therefore, it is contraindicated in clients who have a history of major uterine surgery or cesarean delivery with past pregnancies because of the risk of uterine rupture.

A nurse is reviewing the medical record of a client who is scheduled for induction of labor and has a prescription for misoprostol. Which of the following conditions should the nurse identify as a contraindication to administering this med?

Alterations in the GI flora : The typical GI flora are often destroyed by broad-spectrum antibiotics such as amoxicillin, causing poor digestion n possible superinfection with other bacteria.

A nurse in a provider's office is collecting data from a client who has been taking amoxicillin for 10 days and reports diarrhea and cramping. The nurse should recognize that these manifestations occur secondary to which of the following adverse effects?

"I should check my blood glucose levels more often when I am sick.": Blood glucose levels should be checked every 3 hrs during illness for a client who has Type 1 DM, even if the client consumes fewer calories that usual. Hyperglycemia often occurs w/ an infection, requiring additional doses of insulin

A nurse is reinforcing teaching with a 13 year old client who has Type 1 DM. Which of the following client statements indicates an understanding of diabetes mellitus management?

Chest pain: Chest pain can result if a client takes too much levothyroxine. It is important to increase the dosage gradually to prevent rapid changes in cardiac output that can cause tachycardia and angina, especially for clients who have longstanding hypothyroidism or cardiovascular disorders.

A nurse is reinforcing teaching with a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client to report which of the following manifestations to the provider?

Hot dogs Grapes Bagels Marshmallows

A nurse is reinforcing teaching with a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods should the nurse increase the risks of choking in toddlers?

Decreased estrogen and testosterone production : Both estrogen and testosterone levels start to decrease in middle age

A nurse is reinforcing teaching with a middle adult client about health promotion and disease prevention. The nurse should remind the client that which of the following changes could occur?

Instill a diluted alcohol solution into the ear after swimming : External otitis media is inflammation of the external auditory canal. It is often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal

A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

The old patch should be removed before a new patch is applied: Before applying a new rivastigmine transdermal patch, the client should remove the old patch to prevent toxicity from occurring.

A nurse is reinforcing teaching with the partner of a client who has moderate Alzheimer's disease about a new prescription for a rivastigmine transdermal patch. Which of the following information should the nurse provide?

INR 5.5: A level of 5.5 is considered a critical value and places the client at risk for bleeding; therefore, the nurse should report this result to the provider immediately. A client who is taking warfarin for the treatment of a-fib is expected to have an INR of 2 or 3.

A nurse is reviewing the lab reports for a client who has been taking warfarin for a-fib. Which of the following results should the nurse report to the provider immediately?

An 80 year old client who has a fractured hip

The nurse should know that this is the greatest risk for a complication due to immobility n a lack of lower extremity movement which can lead to DVT. DVT is a causer but venous stasis n blood clot formation in the vascular system n can create pulmonary emboli. The nurse should encourage the client to ambulate as soon as prescribed n implements ROM exercises while on bed rest to prevent DVT