NCLEX

A nurse is preparing 300,000 units of procaine penicillin. The vial contains 1,500,000 units/2mL. How many milliliters will the nurse administer?

0.4 mL

A client has a prescription for 0.25 mg digoxin. The dose on hand is 0.5 mg tablets of digoxin. How many tablets will the client receive?

0.5 tab

A client has a prescription for heparin sodium 7,000 units IV. The vial contains 10,000 units/mL. How many milliliters of heparin will the nurse administer?

0.7 mL

A nurse has available meperidine 50 mg/mL. The prescription is to administer meperidine 35 mg. How many milliliters will the nurse safely administer?

0.7 mL

A patient is being discharged after the insertion of a permanent pacemaker. Which statement made by the patient indicates an understanding regarding appropriate self-care? A) "Each day I'll take my pulse and record it in a log." B) "I'll have to get rid of my microwave oven." C) "I won't be able to use my electric blanket anymore." D) "Every morning I will perform arm and shoulder stretches."

A) "Each day I'll take my pulse and record it in a log."

When measuring a client's output, the nurse records 300 mL of urine at 0800, 450 mL of liquid stool at 1130, 225 mL of urine at 1300, and 35 mL of emesis at 1430. What is the client's total output for this shift?

1,010 mL

A client is receiving dextrose 5% in water at 50 mL/hr in one IV and D5W 75 mL/hr in another IV. The client also receives IV piggyback medication every 8 hr prepared in 100 mL of fluid. What is the total amount of IV fluid the client will receive in 8 hr?

1,100 mL

The IV administration set delivers 10 drops/mL. The rate of flow in drops/min for 1,000 mL dextrose 5% in water to infuse in 8 hr is ____________.

21 drops/min

The IV rate is 100 mL/hr and the administration set is 15 drops/mL. How many drops per minute will deliver the required fluids?

25 drops per minute

A client has the following food for lunch: 8 oz ice chips, 1 cup tea, 1 cup coffee, and 240 mL milk. The client eats the ice chips, and drinks all of the tea, coffee, and half of the milk. The total intake for lunch is _______________.

720 mL

A client weighs 180 lb and has a prescription for 0.5 mL of medication per kilogram of body weight. How many milliliters of medication will the client receive?

41 mL

A nurse is preparing an IV antibiotic in 100 mL dextrose 5% in water to infuse over 20 min. The infusion set is calibrated for 10 drops/mL. What drip rate should the nurse use?

50 drops/mL

A client's IV infusion rate is 75 mL/hr. How many hours will it take for a 500 mL bag of IV fluid to infuse?

6.7 hours

The healthcare provider is performing an assessment on a patient who is taking propranolol (Inderal) for supraventricular tachycardia. Which assessment finding is an indication the patient is experiencing an adverse effect of this drug? A) Urinary retention B) Bradycardia C) Dry mouth D) Paresthesia

B) Bradycardia

A patient who has experienced atrial fibrillation for the past 333 days is admitted to the cardiac care unit. In addition to administering an antidysrhythmia medication, the healthcare provider should anticipate which of these orders? A) Prepare the patient for AV node ablation B) Prepare for immediate cardioversion C) Give atropine IV push D) Initiate a heparin infusion

D) Initiate a heparin infusion

When caring for a patient with a cardiac dysrhythmia, which laboratory value is a priority for the healthcare provider to monitor? A) PT and INR B) Hemoglobin and hematocrit C) BUN and creatinine D) Sodium, potassium, and calcium

D) Sodium, potassium, and calcium Because abnormalities in sodium, potassium and calcium levels are likely to affect depolarization and repolarization of cardiac cells, it is most important for the healthcare provider to monitor these laboratory values.

The healthcare provider is examining the electrocardiogram (EKG) of a patient and notes the PR interval is 666 small boxes in length. What is the significance of this finding? A) This should be documented as an expected finding. B) There may be some scar tissue in one of the ventricles. C) Stress is causing increased sympathetic stimulation. D) There may be a delay in the conduction through the AV node.

D) There may be a delay in the conduction through the AV node

Match the side effect or adverse reaction with the medication or classification. Each should only be used once. 1. ACE inhibitors a. Angioedema 2. Benzodiazepines b. Bronchospasm 3. Beta blockers c. Yellow tinge to vision 4. Ciprofloxacin d. Hypokalemia 5. Digoxin e. Tendon rupture 6. Doxycycline f. Tooth discoloration 7. Furosemide g. Ototoxicity 8. Lithium h. Thrombotic thrombocytopenic purpura 9. Tobramycin i. Anterograde amnesia 10. Valacyclovir j. Tremors

____a____ 1. ACE inhibitors ____i____ 2. Benzodiazepines ____b____ 3. Beta blockers ____e____ 4. Ciprofloxacin ____c____ 5. Digoxin ____f____ 6. Doxycycline ____d____ 7. Furosemide ____j____ 8. Lithium ____g____ 9. Tobramycin ____h____ 10. Valacyclovir

A nurse provides education for a client newly diagnosed with systemic scleroderma. Which information does the nurse include? (select all that apply) a. "Regular therapeutic exercise can prevent excessive skin tightening and promote circulation" b. "Scleroderma is an autoimmune disease that affects skin, blood vessels, muscles, and internal organs" c. "Scleroderma is thought to be caused by a virus or by widespread bacterial infection" d. "Too much collagen is produced in scleroderma, causing thickened skin and occluded blood vessels" e. "Your scleroderma symptoms will be treated with medications called corticosteroids"

a. "Regular therapeutic exercise can prevent excessive skin tightening and promote circulation" b. "Scleroderma is an autoimmune disease that affects skin, blood vessels, muscles, and internal organs" d. "Too much collagen is produced in scleroderma, causing thickened skin and occluded blood vessels" e. "Your scleroderma symptoms will be treated with medications called corticosteroids" Systemic scleroderma (also called systemic sclerosis) is an autoimmune disorder that causes inflammation and sclerosis (hardening) of the skin, muscles, joints, lungs, kidneys, and heart. Treatment includes preventing or treating complications of involved organs. Physical and occupational therapy help maintain function. Drug therapy is limited to relief of symptoms such as pain and Raynaud. Client teaching involves avoiding physical and emotional stress.

A nurse monitors a client with a bowel perforation for the presence of peritonitis. The nurse watches for which manifestation? (select all that apply) a. Absent bowel sounds b. Boardlike abdomen c. Difficulty breathing d. Hypertension e. Septicemia

a. Absent bowel sounds b. Boardlike abdomen c. Difficulty breathing e. Septicemia Peritonitis occurs as a result of the peritoneal cavity being contaminated with bacteria or other chemicals. Bacteria enter the cavity when there is a gangrenous gallbladder, bowel obstruction, infection in the ascending genital tract, or perforation. The body mounts an inflammatory response to wall off the area in order to fight the infection. Vascular dilation occurs along with increased permeability to allow entry of leukocytes. Continued dilation and permeability leads to third-spacing of fluid, and hypovolemic shock may develop. If the body's walling-off mechanism fails to control the problem, inflammation and infection become widespread.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything i've been asked to do!" Which nursing interpretation is best for this situation? a. An expected coping mechanism b. An ineffective defense mechanism c. A need to notify the hospital lawyer d. An expression of guilt on the part of the client

a. An expected coping mechanism The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present

A nurse cares for a client who requires skeletal traction to the lower leg. What interventions does the nurse apply? (select all that apply) a. Assess pin site for signs of infection b. Maintain head of bed at 60 degrees c. Maintain traction at all times d. Perform frequent skin assessments e. Support the weights to prevent injury

a. Assess pin site for signs of infection c. Maintain traction at all times d. Perform frequent skin assessments In skeletal traction, screws are surgically inserted directly into the bone. These allow the use of longer traction time and heavier weights. The priority is maintaining traction and alignment of the limb, preventing infection at the pin sites, and preventing skin breakdown due to immobilization.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? a. Assessment of vital signs b. Completion of abdominal examination c. Insertion of the prescribed nasogastric tube d. Thorough investigation of precipitating events

a. Assessment of vital signs The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a health care provider's prescription; in addition, the vital signs should be check before performing this procedure.

Which medication may be affected by high doses of Allium sativum (Garlic)? a. Clopidogrel (Plavix) b. Alprazolam (Xanax) c. Decetaxel (Taxotere) d. Dextromethorphan (Robitussin)

a. Clopidogrel (Plavix) Allium sativum (Garlic) has been shown to enhance antiplatelet activity and may increase the risk of bleeding in individuals taking antiplatelet or anticoagulation agents.

A nurse manager gathers data for a staff in-service regarding the importance of collaboration and its impact on client outcomes. Which collaboration and client outcomes does the nurse include in the teaching? (select all that apply) a. Decreased mortality b. Decreased nurse turnover rate c. Improved pain control d. Decreased length of stay e. Improved nurse-client ratios

a. Decreased mortality b. Decreased nurse turnover rate c. Improved pain control d. Decreased length of stay Effective professional collaboration leads to improved overall client outcomes. Measured improved outcomes include improved pain control, decreased length of stay, decreased mortality, and a decreased nurse turnover rate. An improved nurse-client ratio does improve client outcomes; however, this is not a result of improved collaboration.

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? a. Elevated on a pillow b. Level with the right atrium c. Dependent to the right atrium d. Elevated above shoulder level

a. Elevated on a pillow The client's operative arm should be positioned so that it is elevated on a pillow and not exceeding shoulder elevation. This position promotes optimal drainage from the limb, without impairing the circulation to the arm. If the arm is positioned flat (option 2) or dependent (option 3), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? (select all that apply) a. Head midline b. Neck in neutral position c. Head of bed elevated 30 to 45 degrees d. Head turned to the side when flat in bed e. Neck and jaw flexed forward when opening the mouth

a. Head midline b. Neck in neutral position c. Head of bed elevated 30 to 45 degrees Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30-45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

A patient with rheumatoid arthritis unresponsive to previous treatments is started on abatacept (Orencia). The nurse should be alert for which common signs or symptoms associated with acute infusion-related reactions? (select all that apply) a. Headache b. Bleeding gums c. Hypertension d. Vomiting e. Dizziness

a. Headache c. Hypertension e. Dizziness Acute infusion-related reactions usually occur within 1 hour of initiation of an IV infusion of abatacept (Orencia).

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? (select all that apply) a. Sitting up and leaning on a table b. Standing and leaning against a wall c. Lying supine with the feet elevated d. Sitting up with the elbows resting on knees e. Lying on the back in a low Fowler's position

a. Sitting up and leaning on a table b. Standing and leaning against a wall d. Sitting up with the elbows resting on knees The client should use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

The nurse performs a musculoskeletal assessment on a client. Which behavior increases the client's risk for osteoporosis? a. The client consumes 400 mg of calcium daily. b. The client drinks a glass of wine each evening. c. The client runs for 30 minutes, three times per week. d. The client has a cup of regular coffee each morning.

a. The client consumes 400 mg of calcium daily. Less than 500 mg of calcium per day is considered a risk factor for osteoporosis. Optimal calcium intake is 1,000 mg per day for adults under 50 years old and 1,200 mg per day for adults over 50 years old. Osteoporosis occurs when the body loses too much bone, makes too little bone, or both. Bones with osteoporosis are porous and have a honeycomb appearance. The bones are weak and at an increased risk for breaks. Some risk factors for osteoporosis (e.g., age, gender, family history, and medical history) are not controllable. Other risk factors (e.g., diet, tobacco use, alcohol use, and exercise habits) can be controlled.

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? (select all that apply) a. The nurse encourages the client and family to identify and discuss feelings openly b. The nurse assists the client and family in carrying out spiritually meaningful practices c. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client d. The nurse makes decisions for the client and family to relieve them of unnecessary demands e. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger

a. The nurse encourages the client and family to identify and discuss feelings openly b. The nurse assists the client and family in carrying out spiritually meaningful practices e. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgemental. The remaining options describe the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. These are ineffective interventions that could impair communication further.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? a. Use of confabulation b. Improvement in sleeping c. Absence of sundown syndrome d. Presence of personal hygiene care

a. Use of confabulation The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.

A client diagnosed with lung cancer is receiving chemotherapy on an outclient basis. The nurse provides what home care instruction to the client? a. "All members of the family can share a bathroom" b. "Contaminated linens should be washed separately" c. "Do not consider tears as contaminated body fluids" d. "Wash hands frequently and dry them using a soft towel"

b. "Contaminated linens should be washed separately" The nurse educates the client receiving chemotherapy that body fluids of the client are contaminated at least 48 hours after receiving chemotherapy. To prevent exposure to others, the client takes care to flush twice after any body fluids enter the toilet, wiping the toilet after use. Also, the client avoids sharing a bathroom if possible. Finally, any contaminated linen or clothing should be washed separately and then can be washed a second time with other laundry to prevent exposure to chemotherapy in body fluids.

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? a. "I will be sure to wash my hands before and after bathroom use" b. "I need to breast-feed, especially for the first 6 weeks postpartum" c. "Support groups are available to assist me with understanding my diagnosis of HIV" d. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery"

b. "I need to breast-feed, especially for the first 6 weeks postpartum" The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the prenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. In the United States and most developed counties, HIV-positive clients are encouraged to bottle-feed their infants (the health care provider's prescription is always followed). Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.

A nurse prepares to administer IV fluids to a client who needs fluids pulled into the vascular system. Which prescription requires the nurse to contact the health care provider? a. 5% dextrose in 0.9% saline at 75 mL/hr b. 5% dextrose in 0.225% saline at 75 mL/hr c. 5% dextrose in 0.45% saline at 75 mL/hr d. 5% dextrose in lactated Ringer's

b. 5% dextrose in 0.225% saline at 75 mL/hr Hypotonic solution contains fewer solutes than the serum, making its osmolarity lower. This will lower the serum osmolarity of the blood and the excess fluid in the blood will move out of the vascular space into the intracellular compartment by diffusion (due to the concentration gradient). The fluid moves to where the solutes are more concentrated to try to balance it out. Hypotonic solutions include 0.45% saline (½NS), 0.225% saline (¼NS), and 0.33% saline (⅓NS). Hypertonic solution contains more solutes than the serum, making its osmolarity higher. This will raise the serum osmolarity of the blood and pull fluid from the intracellular compartment into the vascular space by diffusion (due to the concentration gradient), thus raising the blood volume. Hypertonic solutions include 3% saline, 5% saline, 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (D5NS), 5% dextrose in 0.45% saline (D5½NS), and 5% dextrose in lactated Ringer's (D5LR). Isotonic solution has equal osmolarity compared to normal serum. This does not create a concentration gradient and does not pull fluids into or out of the vascular space, so it allows rehydration that expands blood volume but also allows fluid to move into the intracellular compartment as needed. Isotonic solutions include 0.9% saline, 5% dextrose in water (D5W), 5% dextrose in 0.225% saline (D5W¼NS), and lactated Ringer's.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? a. A pregnant woman who exclaims, "My baby is not moving" b. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" c. A young child standing next to an adult family member who is screaming, "I want my mommy!" d. An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

b. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating whether she is physically hurt.

A nurse cares for a client with fulminant ulcerative colitis (UC). The nurse watches for which associated symptom? a. Acid reflux b. Anemia c. Multiple normal stools each day d. Sudden weight gain

b. Anemia UC correlates with bowel ulceration and dilation, leading to malabsorption of nutrients and diarrhea. These clients may have may bowel movements each day, abdominal discomfort, bloody stools, and anemia. Fulminant colitis refers to the most severe type of UC. These clients have the symptoms of chronic UC such as anemia and malabsorption, but more severe manifestations including more than ten stools per day, continuous bleeding, abdominal pain and distention, fever, and anorexia.

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. What foods should the nurse tell the mother are acceptable to consume while breast-feeding? (select all that apply) a. 1% milk b. Egg yolk c. Dried beans d. Hard cheeses e. Green leafy vegetables

b. Egg yolk c. Dried beans e. Green leafy vegetables Breast-feeding mothers with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are diary products. Alternative calcium sources that can be consumed by the mother include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses.

A nurse prepares a feeding for a client with a nasogastric (NG) tube and discovers it is clogged. Which action does the nurse perform? a. Aspirate from the tube with a syringe b. Flush the tube with water c. Gently move the tube in and out d. Use cranberry juice to dissolve the clog

b. Flush the tube with water A clogged NG tube should be flushed with water to return patency. Flushing with 30mL of water every four hours during continuous feedings and also before and after intermittent feedings will help prevent future clogs. Policies regarding care of NG tubes may vary by agency, and nurses are responsible for knowing their particular facility's policy. A prescription should be obtained for the total amount of free water that can be used each day to flush the tube. For clients who are immunocompromised or severely ill, sterile water should be used.

The nurse performs a focused assessment for a client admitted to the hospital with a suspected myocardial infarction (MI). The nurse is concerned when the client describes referred pain to what location? a. Head b. Left shoulder c. Lower abdomen d. Sternum

b. Left shoulder Acute myocardial infarction, or heart attack, is a condition of the heart where blood flow is restricted to the heart muscle, resulting in tissue damage. This comes from the blockage of one or more of the coronary arteries from buildup of plaque. The most common symptoms of a myocardial infarction are chest pain and shortness of breath. Symptoms are most commonly described as pressure or tightness in teh chest which can radiate to the back, jaw, neck, shoulder, or arms. Other associated symptoms include sweating, nausea, vomiting, anxiety, a cough, dizziness, or a fast heart rate. Not all individuals experience the same symptoms or severity of symptoms.

The nurse educates a teenager recently diagnosed with celiac disease. The nurse includes which information? (Select All That Apply) a. Avoid restaurants due to the risk for accidental exposure to gluten. b. You are also at higher risk for lactose intolerance due to mucosal damage. c. Avoid whole grain rice products that have not had the husk removed. d. Read all labels, as gluten is often in foods you would not expect. e. Symptoms are aggravated with even small exposure to gluten.

b. You are also at higher risk for lactose intolerance due to mucosal damage. d. Read all labels, as gluten is often in foods you would not expect. e. Symptoms are aggravated with even small exposure to gluten. Celiac disease is characterized by villous atrophy in the small intestine, which develops due to a reaction to gluten. Due to an inability to digest the gluten, toxic substances are created and damage mucosal cells. Teenagers often do not want to appear different from their peers, and this places them at greater risk for non-adherence to treatment plans. Acknowledging the challenge and providing accurate information for the client can help improve adherence.

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? a. "I should keep the insulin in the cabinet during the day only" b. "I know I have to keep my insulin in the refrigerator at all times" c. "I can store the open insulin bottle in the kitchen cabinet for 1 month" d. "The best place for my insulin is on the window sill, but in the cupboard is just as good"

c. "I can store the open insulin bottle in the kitchen cabinet for 1 month" An insulin vial is current use can be kept at room temperature for 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Therefore, option 1, 2, and 4 are incorrect.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy is performed. Which response to the family is most appropriate? a. "The decision is made by the medical examiner" b. "An autopsy is mandatory for any client who is DOA" c. "I will contact the medical examiner regarding your request" d. "It is required by federal law. Tell me why you don't want the autopsy done"

c. "I will contact the medical examiner regarding your request" An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

A client newly diagnosed with diabetes mellitus is instructed by the health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse's best response to the client's question? a. "It will boost the cells in your pancreas if you have insufficient insulin" b. "It will help to promote insulin absorption when your glucose levels are high" c. "It is for the times when your blood glucose is too low from too much insulin" d. "It will help to prevent lipoatrophy from the multiple insulin injections over the years"

c. "It is for the times when your blood glucose is too low from too much insulin" Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of glucagon injection. When consciousness has been regained, oral carbohydrates should be given. Lipoatrophy and liphypertrophy result from insulin injections

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? a. "Iron supplements will give me diarrhea" b. "Meat does not provide iron and should be avoided" c. "The iron is best absorbed if taken on an empty stomach" d. "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement"

c. "The iron is best absorbed if taken on an empty stomach" Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? a. 10:00 b. 11:00 c. 17:00 d. 24:00

c. 17:00 Humulin N is an intermediate acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client's health care provider? a. A decreased dosage of levothyroxine b. An increased dosage of levothyroxine c. A decreased dosage of warfarin sodium d. An increased dosage of warfarin sodium

c. A decreased dosage of warfarin sodium Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin should be reduced.

A new mother who wants to breastfeed her baby asks the nurse if she should while she is taking antiretroviral drugs including abacavir (Ziagen). Which response by the nurse is correct? a. Breastfeeding is allowed while taking this drug b. Pumping breast milk and feeding it to the infant in a bottle is allowed c. Breastfeeding is not an option while taking the drug d. Breastfeeding must be supplemented by bottle feeding

c. Breastfeeding is not an option while taking the drug

A nurse assesses a pediatric client with autism spectrum disorder (ASD). Which symptoms suggest a labile mood? a. Repetition of phrases spoken by others b. Repetitive hand movements c. Crying followed by giggling and laughing d. Intense preoccupation with objects that move

c. Crying followed by giggling and laughing Children with ASD often have a labile mood, which is a fluctuating, uncontrolled experience and expression of emotion. Cognitive therapy may be helpful in assisting the child to recognize different emotions and assign appropriate behaviors for each labeled emotion. Drugs such as atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs), and mood stabilizers (e.g., lithium) may be used, although none of these agents has been specifically studied for mood regulation in children with ASD.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? a. Reassure the client that things will get better b. Tell the client that this is not true and that we all have purpose in life c. Identify recent behaviors or accomplishments that demonstrate the client's skills d. Remain with the client and sit in silence; this will encourage the client to verbalize feelings

c. Identify recent behaviors or accomplishments that demonstrate the client's skills Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's pas accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client? a. Restrict the number of family members visiting at one time b. Inform the family that emotional outbursts are to be avoided c. Make the necessary arrangements so that family members can visit d. Contact the health care provider to speak to the family regarding their behaviors

c. Make the necessary arrangements so that family members can visit In the Peurto Rican-American culture, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided, the correct option is the only one that identifies a culturally sensitive approach on the part of the nurse.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? a. Engaging in immoral acts b. Always reinforcing self-approval c. Observing rigid rules and regulations d. Having the need always to make the right decision

c. Observing rigid rules and regulations Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety.

A nurse assesses a hospitalized client after a report of sudden abdominal pain. Which assessment finding does the nurse report to the health care provider immediately? a. Absence of an abdominal bruit b. Left lower quadrant firm to palpation c. Pulsation in the upper abdomen d. Twenty bowel sounds per minute

c. Pulsation in the upper abdomen Pulsation in the upper abdomen, slightly left of midline and between the xiphoid process and umbilicus, indicates an aortic aneurysm. An abdominal aortic aneurysm is a medical emergency and should be reported to the health care provider immediately. A bruit may be heard over the mass. Care should be taken when auscultating, as the mass may be tender and pressure may cause it to rupture. Impending rupture may be signaled by sudden, severe pain in the back or lower abdomen, and it may radiate to the buttocks, groin, or legs.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? a. Adhering to the mandatory abuse-reporting laws b. Notifying the caseworker of the family situation c. Removing the client from any immediate danger d. Obtaining treatment for the abusing family member

c. Removing the client from any immediate danger Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation.

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mmHg, PaO2 of 80 mmHg, and HCO3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis The normal pH is 7.35-7.45. Normal PaCO2 is 35 to 45 mmHg. In respiratory acidosis, the Ph is low and PaCO2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

The nurse monitors continuous bladder irrigation (CBI) on a client who just underwent a prostatectomy. Which finding indicates to the nurse that the CBI flow rate is adequate? a. The client's urine is colorless, odorless, and without sediment. b. The client's urine output equals oral and intravenous intake. c. The fluid in the drainage bag is pale yellow or slightly pink. d. There is 60 mL of fluid in the drainage bag after one hour.

c. The fluid in the drainage bag is pale yellow or slightly pink. The goal of continuous irrigation is to prevent blood clots. The nurse monitors urine output frequently to ensure it is flowing freely and no clots are forming. If urine output slows or stops, assess the patency of the drainage tubing, and assess the client for suprapubic distention or pain. Manual irrigation may be needed if a clot has formed and is occluding the catheter. As postoperative bleeding slows, urine color changes from pink to yellow.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? a. Side-lying with a pillow under the hip b. Prone with a pillow under the abdomen c. Prone in slight Trendelenburg position d. Side-lying with the legs pulled up and the head bent down onto the chest

d. Side-lying with the legs pulled up and the head bent down onto the chest A client undergoing a lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps to open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position.

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? a. The informed consent does not need to be obtained b. The informed consent should be obtained from the family c. The informed consent needs to be obtained from the client d. The health care provider will provide the informed consent

c. The informed consent needs to be obtained from the client Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.

A nurse completes assessments on a group of newborn clients at the beginning of a shift. Which newborn assessment requires priority intervention? a. The newborn, 36 hours' of age, with one bowel movement just after delivery and two wet diapers documented. b. The newborn, 8 hours of age, with only one breast latch immediately after delivery, has blue hands and feet. c. The newborn, 16 hours of age, 68 breaths/min., occasional retractions, and a temperature of 97.6° F (36.44° C) d. The newborn, 6 hours of age, with blood type of B, maternal blood type O, and a positive direct Coombs' screen

c. The newborn, 16 hours of age, 68 breaths/min., occasional retractions, and a temperature of 97.6° F (36.44° C) The intiation and maintenance of respirations and adequate oxygenation is the primary need of the newborn in the first 24 hours of life. Adequate oxygenation enables the newborn to revert to and maintain normal newborn cardiac circulation. A newborn who has compromised respiratory effort has the potential of a return to fetal circulation with a continued downward spiral of oxygenation needs. A newborn who is unable to maintain a stable temperature has increased oxygen demands, further compounding the oxygenation issue.

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? a. "Your hair will need to be shaved" b. "You will receive spinal anesthesia" c. "You will need to ambulate after surgery" d. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery"

d. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery" A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? a. "I need to urinate frequently throughout the day" b. "The prescribed medication must be taken until it is finished" c. "My fluid intake should be increased to at least 3000 mL daily" d. "Foods and fluids that will increase urine alkalinity should be consumed"

d. "Foods and fluids that will increase urine alkalinity should be consumed" A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged

An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? a. "I should obtain new contact lenses" b. "I should not wear my contact lenses" c. "My old contact lenses should be discarded" d. "My contact lenses can be worn if they are cleaned as directed"

d. "My contact lenses can be worn if they are cleaned as directed" If the adolescent wears contact lenses, the adolescent should be instructed to discontinue wearing them until the infection has cleared completely. Obtaining new contact lenses would eliminate the chance of reinfection from contaminated contact lenses and would lessen the risk of a corneal ulceration.

A postoperative patient requests acetaminophen for a headache. The nurse verifies that a PRN order for 500 mg acetaminophen by mouth every 4-6 hours is available in the EMAR. The nurse also sees that the patient has been receiving one tablet of a hydrocodone combination drug (Vicodin) every 6 hours around the clock for chronic pain. Which action by the nurse represents evidence-based care of this patient? a. Hold the PRN dose of acetaminophen (Tylenol) until the provider makes rounds, and then ask if the dose is safe to administer b. Hold the PRN dose while you implement nonpharmacologic measures to reduce the patient's pain c. Administer the PRN dose because there is no known interaction between acetaminophen (Tylenol) and the hydrocodone combination (Vicodin) d. Administer the PRN dose because the total acetaminophen doses for this patient do not exceed the maximum 3g/day and the patient has no evidence of liver or kidney disease

d. Administer the PRN dose because the total acetaminophen doses for this patient do not exceed the maximum 3g/day and the patient has no evidence of liver or kidney disease A total 24-hour dose of acetaminophen (Tylenol) for a healthy patient should not exceed 5g/day. The total dose for this patient prior to administration of the PRN dose is 2000 mg.

On the inpatient medical unit, the nurse observes an adult client suddenly become unresponsive while lying in bed. Which is the best immediate action? a. Provide chest compressions on back board. b. Check pulse and respiratory rate. c. Get the automated external defibrillator (AED). d. Call for help or activate emergency response.

d. Call for help or activate emergency response. Compressions are done after confirming no pulse. Note that it is recommended taking a maximum of ten seconds to assess for pulse so time is not wasted. The nurse calls for help first and then assesses respirations and pulse for no longer than ten seconds before beginning chest compressions, ensuring patent airway and providing ventilation. The nurse should not leave the client. After calling for help, another team member can obtain the AED, if needed. After confirming the client is unresponsive, the nurse activates the emergency response team by calling for help. The nurse should delegate gathering the AED before initiating CPR. Current CPR guidelines include checking for a carotid pulse for no longer than five to ten seconds; if the pulse is absent, start chest compressions to breath ratio of 30:2.

A nurse witnesses an altercation between two clients in a long-term care facility. Which information does the nurse include in the incident report? (Select All That Apply) a. Another client states these two clients don't like each other. b. Clients threaten to hurt each other on a daily basis. c. Provider was not notified since there is no apparent injury. d. Clients are alert and oriented after the altercation. e. Clients separated by nursing assistant 30 seconds after altercation began.

d. Clients are alert and oriented after the altercation. e. Clients separated by nursing assistant 30 seconds after altercation began. Documentation of an incident involving two clients in a client chart should never name the other client involved and should only provide objective information about the incident. The provider should always be contacted whenever an incident of any kind occurs and notification should be included in the incident report.

The provider prescribes allopurinol (Zyloprim) for a patient with primary gout. Which of the following are therapeutic actions of the drug? a. Analgesia b. Anti-inflammatory activity c. Cytotoxicity d. Enzyme inhibition

d. Enzyme inhibition Allopurinol (Zyloprim) reduces uric acid levels by inhibiting xanthine oxidase, the enzyme involved in the conversion of hypoxanthine to xanthine and of xanthine to uric acid

A mother of four children brings her 4-year-old to see the nurse practitioner. He is complaining of severe rectal itching and insomnia. After examining the child, the nurse practitioner determines that the symptoms are due to pinworm infestation. Which information is most important for the nurse to collect prior to treatment with albendoazole (Albenza)? a. Presence of symptoms in other children b. Whether or not a pet is in the home c. Availability of hot water for laundering infested bedding and clothes d. If the mother is pregnant

d. If the mother is pregnant Albendazole (Albenza) should not be administered to pregnant women. The nurse practitioner should confirm the mother's pregnancy status prior to administering the medication

The nurse assess a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? a. Incessant talking and sexual innuendoes b. Grandiose delusions and poor concentration c. Outlandish behaviors and inappropriate dress d. Nonstop physical activity and poor nutritional intake

d. Nonstop physical activity and poor nutritional intake Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

A client with chronic obstructive pulmonary disease (COPD) requires high-flow oxygen supplementation, or precise oxygen concentration, but does not require ventilatory support. Which device does the nurse recognize as appropriate for this client? a. Aerosol mask b. Bilevel positive airway pressure mask c. Nasal cannula d. Venturi mask

d. Venturi mask A venturi mask should be used when the client requires high-flow oxygen at a specific FiO2 concentration. The design of the Venturi mask allows precise delivery of FiO2 while still maintaining high-flow oxygen. The venturi mask is the most accurate, noninvasive oxygen delivery system. Clients at risk for CO2 retention, such as clients with COPD, benefit from a venturi mask because the FiO2 can be controlled. A nasal cannula is low-flow delivery system that does not provide precise FiO2. The aerosol mask is most often used for high humidity or for the use of medication delivery. It does not provide high-flow oxygen or allow for precise control of FiO2 concentration. A bilevel positive airway pressure (BiPAP) mask is used when additional pressure support is needed with ventilation.

Which lab tests should the nurse expect to monitor for a patient receiving amikacin sulfate (Amikin)? a. Hgb/WBC b. Creatinine/Sodium c. ALT/PLT d. WBC/BUN

d. WBC/BUN Amikacin sulfate (Amikin) is used to fight infection. The nurse should follow the WBCs to evaluate the drug's effectiveness. Amikacin sulfate (Amikin) is an aminoglycoside and is nephrotoxic, which would prompt the nurse to follow the patient's renal status. BUN is a lab study that assesses renal function