NCLEX questions 2
The nurse needs to start an IV on an oriented adult. Which supplies will the nurse select? (Select All That Apply)
An arm board or rolled gauze are only necessary for a person that cannot keep the arm straight or picks at the IV site, often because of confusion or other altered level of consciousness. All the other supplies listed are standard.
The nurse is reviewing lab values for a client. Which abnormal serum lab value should the nurse anticipate to stay the same during hemodialysis?
Although hemodialysis improves or corrects electrolyte imbalances such as sodium, potassium and magnesium it has no effect on changing the red cells in conditions such as anemia. Waste products such as creatinine are expected to be lowered with hemodialysis.
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline 25 mg/hour. Which finding would be associated with side effects of this medication?
Aminophylline is a bronchodilator often used to treat symptoms of asthma, bronchitis, and emphysema. Side effects include restlessness and palpitations (it is related chemically to caffeine).
The nurse is assigned to care for a client diagnosed with HIV/AIDS. A first-semester nursing student asks the nurse how a diagnosis of AIDS is determined, other than a positive HIV test. What response by the nurse is the best explanation for how AIDS is diagnosed?
A CD4+ lymphocyte count is normally 600 to 1000 cells per cubic millimeter of blood. The Centers for Disease Control defines AIDS as someone who has a positive HIV blood test, one or more opportunistic infections (such as candidiasis and Kaposi's sarcoma) and a CD4+ lymphocyte count of less than 200. The ELISA Test is used to detect HIV infection; the Western Blot test is used to confirm a positive ELISA test. A viral load test measures the amount of virus in the blood; individuals with higher viral loads are at greatest risk for progressing from HIV infection to AIDS.
A nurse is examining an infant in a clinic. Which nursing assessment for the infant is most valuable in the identification of serious visual defects?
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
A nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. What should the nurse assess next?
A characteristic sign of rubeola is Koplik spots (tiny white spots). These are found on the buccal mucosa in the mouth about a few days before the onset of the measles rash (which appears as small red, irregularly shaped spots with a bluish white center). Although the nurse should assess the child's lungs with any reports of a respiratory infection, these spots would indicate that the skin should be checked for the presence of a rash. Sometimes a complication of measles is pneumonia, but it may be a bit premature to do a sputum culture.
A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin and furosemide. Which finding should the nurse anticipate on an initial assessment?
A client taking a nonpotassium-sparing diuretic, such as furosemide, will likely need a potassium supplement to prevent hypokalemia. This client did not take supplemental potassium. Findings of hypokalemia include weakness and muscle cramps. Hypokalemic clients are more sensitive to digoxin toxicity.
A 14 month-old child ingested half a bottle of aspirin tablets. Which finding should the nurse expect to see in this child?
A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. Spontaneous bleeding often occurs from the nose or mucous membranes in the mouth.
A client has been admitted with a diagnosis of bacterial meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse should expect to see which result?
A positive CSF for bacterial meningitis would include the presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count. If it was viral meningitis, the difference would be that the CSF glucose would be within normal parameters.
Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse?
According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations).
The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.)
Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment.
The nurse is assessing the newborn of a mother with diabetes. The nurse should understand that hypoglycemia is related to what pathophysiological process?
After delivery, high glucose levels, which crossed the placenta to the fetus, are suddenly stopped. The newborn continues to secrete insulin in anticipation of the glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two.
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for a diagnosis of tracheoesophageal fistula (TEF). The mother asks, "When can the tube be used for feeding?" A nurse should respond with which of these comments?
After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more.
The nurse is monitoring a client who is receiving the thrombolytic agent alteplase for treatment of an acute myocardial infarction (AMI). What outcome indicates the client is receiving adequate therapy within the first few hours of treatment?
Alteplase (a t-PA) is used in the management of AMI with ST-segment elevation (STEMI). If thrombolytic therapy was successful, a follow-up ECG will show a reduction of 50% or more in the ST segment. This indicates a return in blood flow to the injured myocardium; however, the ST segment may not return to baseline due to myocardial damage. The other responses are incorrect: successful thrombolysis can cause a variety of cardiac arrhythmias; cardiac enzymes peak 8 hours or more after an AMI; and blood pressure may be unstable.
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which growth or development parameter should be of the most concern to a nurse?
Although a lot of factors affect weight gain, birth weight usually doubles by 5 months and triples by about 12 months. Between 6 months and 2 years, head circumference and chest size are about the same. A 10 month-old may be able to stand alone (very briefly) or even walk unassisted. Stranger anxiety also starts around this time.
A nurse is caring for a 10 year-old child who will be started on heparin therapy. Which assessment is critical for the nurse to make before initiating this therapy?
Check the client's weight because the dosage for anticoagulants in children is calculated on the basis of weight.
A nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding should the nurse anticipate?
Consolidated lung tissue contains exudate from the infectious process, changing the infected portion of the lung tissue from air-filled to fluid-filled, and increasing the ability of the affected lung field to transmit sounds. Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.
Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy?
Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level.
A nurse is providing discharge teaching to a client who has a new diagnosis of renal calculi. Which point should be included as a dietary recommendation to prevent recurrence of this condition?
During examination of the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of these conditions would most likely explain these findings?
A client is being discharged home today and will be taking potassium (K-Dur) 20 mEq per day by mouth. What should the nurse advise the client to avoid due to its effects of lowering serum potassium levels?
Excessive intake of black licorice can lead to decreased serum potassium due to the effect of glyceric acid (aldosterone effect). The excessive use of salt substitutes (which usually contain potassium chloride), potassium-sparing diuretics and NSAIDs have the potential for raising potassium levels.
A nurse is preparing to administer morning medications to a 12 year-old client with heart failure. The child's morning lab values are: sodium 142 mEq/L (142 mmol/L), potassium 2.9 mEq/L (2.9 mmol/L), digoxin level 1.4 ng/mL. Which of the following medications should the nurse not administer until after speaking with the health care provider?
Ferrous sulfate Submit Because the potassium levels are low (normal is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L), the nurse should not give the digoxin; hypokalemia can predispose a person to digoxin toxicity. The other medications can be administered. Although carvedilol can increase plasma digoxin concentration, the digoxin level is normal. Spironolactone is a potassium-sparing diuretic and because the potassium level is low, this too can be given. Ferrous sulfate does not affect the given lab values.
The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin?
Food-borne botulism can be treated by removing whatever contaminated food is in the stomach by using enemas (or by inducing vomiting) and administering a Botulinum antitoxin. Children with iron poisoning and who are breathing normally can be given a strong laxative fluid; severe poisonings require IV chelation therapy. For NSAID poisoning, sometimes activated charcoal is given (usually within 1 hour of ingestion); massive overdoses may require orogastric lavage because there is no specific antidote for ibuprofen. Since laundry detergent is an alkaline substance, the most commonly used therapy is dilution/irrigation/wash, especially for burns to the skin and eyes. Tracheal intubation with ventilation may be required if the child swallowed the laundry detergent.
The nurse is having a discussion with the parents of a newborn who was diagnosed with hypospadias. The nurse should communicate which point?
Hypospadias is a condition in which the urethral opening is located on the ventral surface or the underside of the penis. Mild defects may be repaired in one procedure, while severe defects may require two or more procedures. It is corrected in stages as soon as the child can tolerate surgery and before the child turns school age.
The home health nurse is visiting a client recently discharged after an episode of acute pyelonephritis. Which nursing action should take the highest priority?
The priority nursing action is to determine whether the antibiotic therapy has been effective in treating this serious kidney infection. Fever, flank pain, nausea and vomiting would be indicators that the antibiotic therapy has not been effective, requiring contact with the provider for further treatment orders.
A client with an IV antibiotic infusing is scheduled to have blood drawn at 1:00 pm for a peak antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and won't be infused until 1:30 pm. What action should the nurse take?
If the antibiotic infusion will not be completed at the time the peak blood level is scheduled to be drawn, a nurse should ask that the blood sampling time be adjusted. Typically the peak level should be drawn about 30 to 60 minutes after completion of the infusion. The infusion should not be increased because in this situation the volume of fluid to be infused is unknown; rates for IV infusions should not be increased or decreased by more than 10% of the ordered rate. Trough and/or peak levels are commonly drawn for aminoglycosides (such as vancomycin, gentamicin, and tobramycin.)
A client is being discharged with a prescription for an iron supplement. What statement indicates a need for further teaching by the nurse?
Iron should also be taken with vitamin C or orange juice because this increases the absorption of the medication; conversely, antacids, milk, caffeinated beverages, and calcium supplements can decrease the absorption of iron. Iron will cause the client's stool to turn greenish-black and tarry. Iron should be taken one hour before or two hours after meals to enhance absorption, although clients with GI intolerance may take the pills with food.
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?
Lactulose is a synthetic sugar used to treat constipation and reduce the amount of ammonia in the blood of clients with liver disease. It works by drawing ammonia from the blood into the colon, where it is removed by the body. Hepatic encephalopathy (HE) occurs in people with end-stage liver disease. People with HE may experience problems with memory, concentration and may experience drowsiness and lethargy; lactulose is used to help manage these symptoms. Lactulose is not used to treat edema or jaundice.
The nurse observes a family member administer a rectal suppository. The family member turns the client to lie on the left side, pushes the suppository in with one finger up to the second knuckle, removes the finger, and then waits 10 minutes before turning the client to the right side. What is the appropriate comment for the nurse to make?
Left side-lying position is the optimal position for clients to receive rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. The suppository should be somewhat melted after 10 to 15 minutes and the client can move into any position of comfort. There is no data in the stem to support any of the other options.
The client was admitted two days ago with a diagnosis of myocardial infarction (MI). When assessing this client, the nurse notes the client's temperature is now 101.1 F (38.5 C). What is the most appropriate nursing intervention?
Leukocytosis and fever are common outcomes on day two after a heart attack because of the inflammatory process associated with an acute MI. Nursing interventions should focus on the promotion of comfort.
An 8 year-old child is hospitalized with minimal-change disease (MCD). The nurse assists the child to select a lunch menu. Which menu selection is the best choice?
MCD is a kidney disease in which large amounts of protein are lost in the urine. Corticosteroids are used to treat the disease; ACE inhibitors and diuretics are used to treat the edema. Treatment also includes eating a healthy, low-sodium diet with high-quality protein. Of the given choices, grilled chicken strips, corn on the cob and a glass of skim milk has the smallest total sodium content (less than 500 mg) and is the healthiest diet. Since nearly every layer of a sandwich is loaded with salt, the bologna and cheese sandwich (with around 1260 mg sodium) and the frankfurter on the bun (717) are not the best choices. However, the peanut butter and sliced banana sandwich, apple and milk option is a close second (about 650 mg sodium.)
The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which of the following findings would support the nurse's suspicion that the client has developed a fat embolism? (Select all that apply.)
Manifestations of acute confusion, hypoxia, fever and hypotension may indicate fat embolism in a client who has sustained multiple fractures, particularly fractures of the long bones. The occlusion of dermal capillaries by fat with increased friability of the capillaries can result in skin petechiae. This is most common on the chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctiva.
A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect?
Oculogyric crisis
A 32 year-old female with human epidermal growth factor receptor 2-positive (HER2-positive) metastatic breast cancer is scheduled to begin therapy with pertuzumab. What information is important for the nurse to reinforce and discuss with the client? (Select all that apply.)
Pertuzumab (Perjeta) is used in combination with trastuzumab (Herceptin) as a targeted therapy for HER2+ metastatic breast cancer; these meds are used in combination with chemotherapy and radiation. The most common side effects are fatigue, loss of taste, muscle pain, and vomiting; sometimes slowing the infusion rate can help. It is best to eat a small meal before receiving the infusion. Serious side effects include birth defects and fetal death; women of child-bearing age must use a form of effective contraception during and for 6 months following treatment. Drugs that block HER2+ activity decrease left ventricular ejection fraction (LVEF) and will worsen symptoms of congestive heart failure; heart function must be tested before and monitored during treatment.
The health care provider orders potassium iodide (SSKI) drops for a client scheduled to undergo a thyroidectomy. How should the nurse administer the medication?
Potassium iodide drops should be mixed with water, fruit juice, milk, broth or even formula; the client can use a straw to drink the mixture. To minimize gastrointestinal irritation, it can be given after meals or with food. The medication is used preoperatively, 10 to 14 days before surgery, to reduce the size and vascularity of the thyroid gland.
A 42 year-old male client diagnosed with hypertension tells the nurse he no longer wants to take propranolol. Which client statement best explains the reason why he does not want to take this medication?
Propranolol is a beta-blocker used to treat many conditions, such as essential tremors, angina, hypertension, and heart rhythm disorders. Common side effects of this drug include nausea, diarrhea, constipation, stomach cramps, rash, tiredness, dizziness, sleep problems, and vision changes. Additionally, propranolol may cause decreased sex drive, impotence or difficulty having an orgasm in men. The clients can be switched to an alternative antihypertensive, such as an angiotensin-converting enzyme (ACE) inhibitor or a calcium channel blocker.
An infant has just had a pyloromyotomy. Initial postoperative nursing care would include which of these approaches?
Pyloric stenosis is caused when a muscle between the stomach and duodenum grows too large and thick, blocking food from being pushed from the stomach into the duodenum. During a pyloromyotomy, the surgeon cuts through the thickened muscle. Postoperatively, the initial feedings for infants are small quantities of clear liquids, such as glucose water or water with electrolytes in it. If the infant tolerates clear liquids, caregivers will give watered-down breast milk or formula; feedings are then advanced to regular breast milk or formula.
A nurse admits a premature infant who has been diagnosed with respiratory distress syndrome (RDS). In planning care for the infant, the nurse understands that the pathophysiology of this disorder affects the infant's ability to do what?
RDS is primarily a disease related to a developmental delay in lung maturation. Although many factors may lead to the development of the disorder, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development because the infant is premature. A lack of surfactant production results in the collapse of the alveolar sacs.
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
Respiratory infections are a common complication of pancreatitis because fluid in the retro-peritoneum can push up against the diaphragm, causing shallow respirations. Coughing and deep breathing every two hours will diminish the occurrence of this complication. The other interventions are not appropriate, and the client will be NPO during the initial period of treatment for pancreatitis.
A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to be ordered as a combination drug therapy regimen? (Select all that apply.)
Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in symmetric joint destruction. Research shows that multiple drug therapy is most effective in protecting against further destruction and promoting function. Analgesics and anti-inflammatory drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help slow or stop progression of RA. Biological response modifiers are used to help stop inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to ease the pain and stiffness of affected joints. Because RA is not an infectious disease, antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics are not part of the treatment plan.
A nurse is caring for a client who has just been admitted with an overdose of aspirin. The following lab data is available: PaO2 95, PaCO2 30, pH 7.5, K 3.2 mEq/L. Which should be the nurse's first action?
Side effects of aspirin toxicity include hyperventilation, which can result in respiratory alkalosis in the initial stages. Breathing into a paper bag will prevent further reduction in PaCO2.
The nurse is applying silver sulfadiazine topical to severe burns on the arms and legs of an adult. Which side effect should the nurse monitor for?
Silver sulfadiazine (Silvadene) is a broad spectrum antimicrobial and is especially effective against pseudomonas. When applied to extensive areas, however, it may cause a transient neutropenia, a decrease in neutrophils, as well as renal function changes with sulfa crystal production and kernicterus.
The nurse is caring for a client with chronic renal failure who is undergoing peritoneal dialysis. The nurse notes that the dialysate solution is instilling very slowly. Which of the following actions would be appropriate for the nurse to implement? (Select all that apply.)
Slow dialysate instillation may be due to a partially obstructed tube or catheter. Checking for kinks and repositioning may facilitate improved instillation of this fluid. Assessment for bruit or headache and hypertension are appropriate for hemodialysis situations, not peritoneal dialysis.
The mother of a child diagnosed with poison ivy tells the nurse that she does not know how her child contracted the rash because the child had not been playing in wooded areas. As the nurse asks questions about possible contact, which of these situations should the nurse recognize as the highest risk for exposure to poison ivy?
Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis. Throwing a ball to a child with the rash is not a highest risk because direct contact has the greatest risk.
A client was admitted to the psychiatric unit diagnosed with major depressive disorder (MDD) after a suicide attempt. Which of the following findings of MDD would the nurse expect the client to exhibit?
Somatic or physiologic findings of depression include: fatigue, psychomotor retardation or agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido. The other factors in the options are not a consideration for major depression.
The caregiver of a client with Alzheimer's disease asks the nurse for information about different treatment options that can help with memory or behavior problems. Which of the following responses by the nurse are correct? (Select all that apply.)
Some complementary and integrative health therapies may help with the symptoms of Alzheimer's disease. Music, art and dance therapies can help with behavior issues. Ginkgo biloba may be used to improve memory. Acupuncture may be a frightening experience for someone with Alzheimer's disease. Garlic is not a treatment for Alzheimer's disease. Donepezil (Aricept) is used to ease the symptoms associated with Alzheimer's disease.
A nurse is administering lidocaine to a client with a myocardial infarction. Which assessment finding requires the nurse's immediate action?
Some of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest. This medication should not be administered without continuous cardiac monitoring.
The nurse is assessing a 72 year-old client with a full-leg cast on his left leg three days after cast application and finds bilateral pedal edema. Based on this finding, what condition should the nurse consider?
Swelling after injury or surgery and reduction usually peaks within 24 to 48 hours, with only minimal swelling expected afterwards. If the client had pedal edema only on the casted leg, the nurse should consider extension of the initial injury/trauma, compartment syndrome, or thrombophlebitis. However, with bilateral pedal edema, the nurse should consider right-sided heart failure.
The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true about tardive dyskinesia?
Tardive dyskinesia (TD) is an extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early symptoms of TD are fasciculations of the tongue or constant smacking of the lips. Neuroleptic malignant syndrome is a more serious side effect of antipsychotic medications in which the client presents with hyperthermia, rigidity, and autonomic dysregulation (hypertension, tachycardia, tachypnea, agitation, diaphoresis). TD can be treated with the anticholinergic medication benztropine; therapy is started with a low dose and gradually increased to find the smallest amount necessary for relief. Tourette syndrome is a movement disorder, but it is unrelated to TD.
A nurse is caring for a 13 year-old after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? (Select all that apply.)
The client should remain flat in bed for at least 6 hours and turned from side to side every 2 to 4 hours. The day after surgery, the client can sit up in bed a few times; the client will get out of bed to sit in a chair on the second or third day after surgery. Clients should be encouraged to perform isometric exercises right after surgery. Neuro checks will be performed every 2 hours for the first 24 hours.
During examination of the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of these conditions would most likely explain these findings?
The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel's porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or the drinking water with high levels of fluoride.
The oncology client is using patient controlled analgesia (PCA) with morphine for pain control. The client reports having pain and states it is a 7 (on a scale of 0 to 10). Indicate the correct sequence of nursing interventions by dragging and dropping the sentences in the correct order. Ensure the client is using the PCA equipment properly Confirm that there is power to the pump and the tubing is patent Assess the level of consciousness and respiratory status Check the chart for orders for treating breakthrough pain Consult with the health care provider
The nurse must ensure that the client understands how to use the PCA and should have the client demonstrate how to push the button. If indeed the client is using the PCA properly, then the nurse must ensure the machine is mechanically sound, i.e., the power is on, tubing connected and not kinked, etc. Because narcotics can cause sedation and respiratory suppression, the nurse must determine that these are not problems. The nurse can then check to see if there is an order for breakthrough pain. The last step would be to consult with the health care provider, possibly for further orders.
The nurse is planning care for a 3 month-old infant in the immediately postoperative period after the placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse should take which action with anticipation of complications of the procedure?
The nurse should observe for abdominal distention or a taunt abdominal wall because cerebrospinal fluid could cause peritonitis or a postoperative ileus as a complication of distal catheter placement. The child may be in a car seat afterwards. However, it does not answer the question being asked about potential complications. The infant would be started on clear liquids initially, not formula. The shunt will not be pumped.
Postoperative orders for a client who had a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. What is the purpose of these actions by a nurse?
The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure. Pulmonary artery pressures are an assessment tool used to determine the ability of the heart to receive and pump blood effectively.
Which of these client's behaviors would indicate that the nurse-client relationship has passed from the orientation phase to the working phase?
The working phase of the nurse-client relationship is also called exploration or the identification stage. That's because the client identifies his/her problems and works with the nurse to solve problems and develop coping skills, a positive self concept and, eventually, independence. These skills will help the client to adapt and behave more appropriately.
A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement but no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? (Select all that apply.)
This client needs emergency treatment to open the airways and improve gas exchange. The absence of lung sounds without wheezing indicates a severe narrowing of the airways in asthma with minimal air movement. Emergent intervention to open the closed airway including possible intubation are indicated. The high PaCO and low pH indicate respiratory acidosis due to inadequate gas exchange. The low oxygen saturation and PaO2 indicate severe hypoxemia requiring high flow oxygen via mask.
A client, who had his entire stomach surgically removed six months ago, is now readmitted. Which of the following assessment findings would indicate that the client is experiencing complications associated with this surgery?
When clients have the stomach surgically removed, they no longer have the stomach's production of intrinsic factor, leading to poor Vitamin B12 absorption. This results in anemia with symptoms of fatigue, due to the decreased number of red blood cells to carry oxygen to the body. The client with gastrectomy or gastric bypass surgery is also at risk of experiencing dumping syndrome with abdominal cramping pain, diarrhea, lightheadedness, tachycardia and hypoglycemia. Dumping syndrome is usually associated with eating too much or too rapidly, and can be avoided by following the proper diet (five to six small meals per day, high protein, low carbohydrate and fat, eaten slowly) and by avoiding fluids with meals that move food rapidly into the small intestine.
Sputum culture results for a client admitted with a cough and fever indicate a methicillin-resistant Staphylococcus aureus (MRSA) infection in the nares. What nursing intervention must now be taken? (Select all that apply.)
When possible, a private room would be best, but cohorting is often used for multidrug resistant organisms such as MRSA. If the client needs to be transported to another area, the client should wear a mask, especially if there's a productive cough. Staff should practice excellent hand hygiene and other standard precautions, but a respirator is not needed for MRSA in the nares. To minimize the risk of spreading infection, equipment or personal items should kept in the client's room and dedicated for his/her use.
A 54 year-old female explains to the health care provider that she experiences approximately 10 vasomotor symptoms of menopause ("hot flashes") throughout the day and night. Different treatment options are discussed. Which statement by the client indicates she needs further instruction from the nurse?
n addition to menopausal hormone therapy (MHT), medications for epilepsy (gabapentin), depression (SSRIs) and hypertension can be used to treat hot flashes. Extended release gabapentin is taken at bedtime to treat insomnia due to hot flashes. Although the risk of low-dose estrogen is small, there is still a risk of breast cancer, heart attack, and blood clots with menopausal hormone therapy (MHT), which is why it should only be a short-term treatment option. Non-medical interventions include avoiding spicy foods, alcohol, and caffeine. Clients should also dress in layers, use fans for cooling and try taking slow, deep breaths when a hot flash starts.
