NCLEX Study Questions by BECCA

3 (Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, Metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.)

A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1 "I will take the drug with food." 2 "I must swallow my medication whole and not crush or chew it." 3 "I will stop taking Metformin for 24 hours before and after having a test involving dye." 4 "I will notify my doctor if I develop muscular or abdominal discomfort."

2 3 (Lithium carbonate therapy can negatively affect thyroid function; the client's current TSH is at the high normal level and so frequent checks are appropriate. Low serum sodium levels would result in the kidneys' reabsorbing the lithium; this situation would lead to lithium toxicity. The health care provider must first be notified of the lab result. Lithium is not known to have a negative effect on WBC, platelet, or RBC production. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.)

A client has been found to have bipolar disorder and is being prescribed lithium carbonate (Lithium). In light of the information shown, the nurse provides teaching to the client. Select all that apply. 1 Lithium can affect WBC production and therefore increases her risk for infection. 2 Her current thyroid function will require frequent assessments while she takes lithium. 3 Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level. 4 Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy. 5 The current hemoglobin and hematocrit call for regular monitoring is needed once the lithium level is stabilized.

4 (The health care provider is responsible for prescribing medications but depends on the nurse's observations before making decisions. This is not a severe enough finding to warrant withholding the drug. It is a reaction to the risperidone (Risperdal), and it is not transitory. Giving the client finger exercises will have no effect on the tremors.)

A client on the psychiatric unit who is receiving high-dosage risperidone (Risperdal) is exhibiting tremors of the hands. What should be the nurse's first intervention? 1 Withholding the medication 2 Telling the client it is transitory 3 Giving the client finger exercises 4 Contacting the health care provider

4 5 (Cognitive therapy seeks to find underlying self-defeating beliefs and replace them with more reality-based positive beliefs. It encourages the use of cognitive restructuring (cognitive reframing) through positive self-talk and a rational mindset. Teaching the client relaxation exercises to diminish stress reflects a behavioral approach. Exploring with the client past experiences that have caused distress is a psychoanalytical approach. Providing the client with mastery experiences to boost self-esteem is a behavioral approach.)

A client states, "I get down on myself when I make a mistake." In a cognitive therapy approach, which nursing interventions are most appropriate? Select all that apply. 1 Teaching the client relaxation exercises to diminish stress 2 Exploring with the client past experiences that have caused distress 3 Providing the client with mastery experiences designed to boost self-esteem 4 Encouraging the client to replace these negative thoughts with positive thoughts 5 Helping the client modify the belief that anything less than perfection is unacceptable

2 (Doxorubicin causes the urine to turn red for a few days; the client should be informed of this expectation so as not to become alarmed when it occurs. Discontinuing the intake of vitamin D is true for plicamycin (Mithramycin), not the drugs in this protocol. It is unnecessary to keep doxorubicin (Adriamycin) in a dark area, protected from light. Doxorubicin is not given orally, only via the intravenous route.)

A client with Hodgkin's disease is placed on an ABVD combination chemotherapy regimen. Because doxorubicin (Adriamycin) is part of this therapy, the nurse should teach the client to: 1 Cease taking any medication that contains vitamin D 2 Expect urine to turn red for a few days after taking this drug 3 Keep the doxorubicin in a dark place protected from light 4 Take the doxorubicin on an empty stomach with large amounts of fluids

3 (The parkinsonian signs and symptoms are related to extrapyramidal tract effects, and agranulocytosis is related to bone marrow depression. Jaundice is an adverse reaction; vomiting is not. Tardive dyskinesia is an adverse reaction; nausea is not. The occurrence of orthostatic hypotension is low; hiccups usually do not occur.)

A client with an organic mental disorder becomes increasingly agitated and abusive. The practitioner prescribes haloperidol (Haldol). For what untoward effects should the nurse assess the client? 1 Jaundice and vomiting 2 Tardive dyskinesia and nausea 3 Parkinsonism and agranulocytosis 4 Hiccups and postural hypotension

2 5 6 (The normal blood urea nitrogen concentration ranges from 8 to 20 mg/dL. An increased level is seen in renal damage. The normal serum albumin concentration ranges from 3.4 to 5.4 g/dL. A low level is characteristic of liver damage. The normal prothrombin time for someone who is not taking a blood thinning medication is 11 to 13.5 seconds. A prolonged prothrombin time may be the result of liver damage. The therapeutic lithium level ranges from 0.6 to 1.4 mEq/L. A lithium level of 1.2 mEq/L is well within normal limits and requires no intervention. The normal hematocrit ranges from 35% to 47% in females and 42% to 52% in males. The normal sodium range is 136 to 145 mEq/L.)

A client with bipolar disorder has been admitted for alcohol detoxification, and laboratory tests are performed. Which results should prompt the nurse to notify the admitting health care provider? Select all that apply. 1 Lithium level: 1.2 mEq/L 2 Blood urea nitrogen: 25 mg/dL 3 Hemocrit: 47% 4 Serum sodium: 140 mEq/L 5 Serum albumin: 2.9 g/dL 6 Prothrombin time: 13.9 seconds

4 (A 6-year-old child should have resolved the previous developmental conflicts of trust versus mistrust (infancy) and autonomy versus shame and doubt (toddlerhood). During the preschool years children learn to assume responsibility for themselves and their possessions as well as develop more socially acceptable behavior (initiative versus guilt). Resolution of identity versus role confusion occurs at adolescence. Resolution of industry versus inferiority does not occur until the end of the school-age years. Resolution of intimacy versus isolation occurs at adulthood.)

A nurse concludes that a 6-year-old child who has attained an acceptable level of psychosocial development has achieved Erikson's developmental conflicts related to trust, autonomy, and: 1 Identity 2 Industry 3 Intimacy 4 Initiative

2 (In a circumstantial thought process, excessive and unnecessary detail, usually relevant to the question, ultimately gives way to an answer. Flight of ideas is rapid shifting from one topic to another and fragmentation of ideas. Thought blocking is a sudden stoppage of the train of thought or in the middle of the sentence. Tangential thinking is similar to circumstantial thought processes, but the person never answers the question or returns to the central point of the conversation.)

A nurse has just completed a mental status examination on a newly admitted psychiatric client and returns to the nurses' station to document the results. The nurse reflects on the client's drawn-out explanation of the reason for the admission and concludes that excessive detail was given before the client eventually answered the questions. What mental process does the nurse identify? 1 Flight of ideas 2 Circumstantiality 3 Thought blocking 4 Tangential thinking

doxorubicin

Antineoplastic: anthracycline drug (cell cycle−nonspecific); intercalates between base pairs to disrupt DNA functions and forms cytotoxic free radicals. Toxicity: cardiotoxicity, myelosuppression

2 (Regular insulin is short acting, and it peaks in two to four hours, which in this case will be at or before lunch.)

Daily Humulin R insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 AM. When should the nurse monitor the client for a potential insulin reaction? 1 At breakfast 2 Before lunch 3 Before dinner 4 In the early afternoon

4 5 (Doxepin (Sinequan), because of its significant anticholinergic properties, can lead to urine retention, particularly in older men. Doxepin may cause an increase in psychiatric symptoms and precipitate suicidal ideation. Doxepin may cause constipation, not diarrhea. Doxepin may cause an increase, not a decrease, in appetite. Although photosensitivity is a side effect of doxepin, it can be managed through nursing interventions such as avoiding the sun, wearing clothing, and using sunblock.)

Doxepin (Sinequan) is prescribed for a 74-year-old man for treatment of a depressive episode that has not responded to several other medications. The nurse in the outpatient clinic reviews with the client the side effects of doxepin. The identification of which side effects by the client as needing to be reported to the health care provider allows the nurse to conclude that the teaching has been effective? Select all that apply. 1 Diarrhea 2 Loss of appetite 3 Photosensitivity 4 Retention of urine 5 Thoughts of suicide

left

Oliguria, pallor, and cool extremities are key features of ______-sided heart failure. +pulmonary congestion & pulmonary edema (AEB dyspnea and crackles)

3 (The QRS complex represents ventricular depolarization. The P wave represents atrial depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, visualization of atrial repolarization is obscured by the QRS complex. The T wave represents ventricular repolarization.)

The QRS complex represents: 1 Atrial depolarization. 2 Atrial repolarization. 3 Ventricular depolarization. 4 Ventricular repolarization.

T wave repolarization Vfib

The __-______ is the period of _______________ of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation (_____).

allopurinol

What is the drug of choice for treating a patient with hyperuricemia due to overproduction of uric acid?

2 (Tachycardia, hyperpyrexia, and tachypnea are indications of neuroleptic malignant syndrome, which is a life-threatening complication. Restraint of any type may worsen the client's anxiety and result in struggling and increased agitation. Photosensitivity occurs most commonly when clients are taking large doses and are spending time outdoors in the sun, but it is not life threatening. Tardive dyskinesia usually results from prolonged large doses of phenothiazines in susceptible clients, but it is not life threatening.)

client is started on chlorpromazine (Thorazine). To prevent life-threatening complications from the administration of this medication to an anxious, restless client, it is important that the nurse: 1 Provide adequate restraint. 2 Monitor the client's vital signs. 3 Protect against exposure to direct sunlight. 4 Watch the client for extrapyramidal side effects

3 (Applying stockings while the legs are horizontal before arising ensures that stockings are in place before dependent edema occurs. The nurse legally cannot recommend medications. Warm soaks resolve inflammation; they do not prevent development of thrombophlebitis. Although helpful, following the prescribed exercise program will not provide continuous support for the veins, which is necessary.)

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client? 1 Take a baby aspirin every day. 2 Place a warm soak on the legs daily. 3 Apply elastic stockings before arising. 4 Follow the prescribed exercise program

2 (As a result of increased cortisol levels, glucose metabolism is altered, which may contribute to an increase in blood glucose levels. Increased mineralocorticoids will decrease urine output. Sodium is retained by the kidneys, but potassium is excreted. The immune response is suppressed.)

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? 1 Urine output 2 Glucose level 3 Serum potassium 4 Immune response

2 (Nausea and vomiting, accompanied by diffuse abdominal pain, commonly occur in clients with small bowel obstruction; the vomiting may be projectile and may contain bile or fecal material. Hematemesis is associated more closely with peptic ulcer disease. Bleeding with defecation is associated with hemorrhoids and anal fissures. Pain in the left lower quadrant is associated with diverticulitis. Pain associated with a small bowel obstruction usually is more diffuse.)

A client with severe Crohn's disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report? 1 Bloody vomitus 2 Projectile vomiting 3 Bleeding with defecation 4 Pain in the left lower quadrant

4 (Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure.)

A nurse expects that a client with right-sided heart failure will exhibit: 1 Oliguria 2 Pallor 3 Cool extremities 4 Distended neck veins

1 2 4 (Nausea and vomiting may occur; it reflects a central emetic reaction to levodopa. Anorexia may occur; decreased appetite results because of nausea and vomiting. Changes in affect, mood, and behavior are related to toxic effects of the drug. Tachycardia and palpitations, not bradycardia, occur. Peripheral edema is not a side effect of carbidopa-levodopa.)

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? Select all that apply. 1 Vomiting 2 Anorexia 3 Slow heart rate 4 Changes in mood 5 Peripheral edema

plicamycin

Cytotoxic antibiotic used to treat Paget's disease and hypercalcemia

Vitamin D

Discontinuing the intake of __________ ___ should occur with plicamycin (Mithramycin)

1 (Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock.)

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism causes: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

methimazole

MOA: Block thyroid peroxidase, inhibiting the oxidation of iodide and the organification of iodine --> inhibition of thyroid hormone synthesis

4 (Reducing the blood ammonia level decreases the effect of bacterial activity on blood and wastes in the gastrointestinal tract. Although neomycin is an aminoglycoside antimicrobial, it is not administered to prevent infection. Neomycin has little or no effect on intestinal edema. Neomycin does not reduce abdominal distention.)

Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication? 1 Prevents an infection 2 Minimizes intestinal edema 3 Limits abdominal distention 4 Reduces the blood ammonia level

1 (Bleeding and hemorrhage are the most serious concerns. Bleeding disorders are common when bile does not flow through the intestine. Vitamin K, a fat-soluble vitamin synthesized in the small intestine, requires bile salts for its absorption; vitamin K is used by the liver to synthesize prothrombin necessary for clotting. Preventing pressure on the suture site, encouraging use of an incentive spirometer, and detecting clinical manifestations of inflammation are not as serious concerns.)

On which of the following should the nurse focus when caring for a client after abdominal surgery? 1 Identifying signs of bleeding. 2 Preventing pressure on the suture site. 3 Encouraging use of an incentive spirometer. 4 Detecting clinical manifestations of inflammation.

4 (The response about taking one tablet before attempting to climb two flights of stairs indicates that the client understands the nurse's teaching. Taking a nitroglycerin tablet before such an activity probably will prevent an episode of angina, which is an example of prophylactic use of a medication. Taking the medicine three times a day is an example of scheduled administration of a medication, not prophylactic use. The statement to avoid activities that are too strenuous indicates avoidance of activity rather than taking medication to prevent angina during the activity. Blood pressure, not pulse, is the parameter most affected by nitroglycerin.)

Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. The statement by the client that indicates the teaching was effective is, "I should: 1 ... take the medicine three times a day." 2 ... avoid activities that are too strenuous." 3 ... be sure to take my pulse after I have exercised." 4 ... take one tablet before attempting to climb two flights of stairs."

desmopressin acetate

The primary pharmacologic treatment for diabetes insipidus is replacement of ADH with an exogenous vasopressin, such as _____________ __________ (DDAVP).

3 (Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes. Creatinine, a nitrogenous product of protein breakdown, is increased with renal insufficiency. WBC count does not measure kidney function; white blood cells usually are depressed because of immunosuppressive therapy to prevent rejection. WBC count is more valuable for assessing structure than function. Although 24-hour urinary output should be considered, it is not as definitive as the serum creatinine level.)

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning? 1 White blood cell (WBC) cell count 2 Renal ultrasound 3 Serum creatinine level 4 24 hour urinary output

Convulsions muscle spasms paresthesias

______________ can occur with hypocalcemia, hypernatremia, and hyponatremia. __________ _________ can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; ______________ are associated with hypocalcemia and hyperkalemia.

Demeclocycline

__________________ is used to treat syndrome of inappropriate antidiuretic hormone (SIADH), a condition of overproduction of ADH.

borborygmi

loud, gurgling bowel sounds signaling increased motility or hyper peristalsis, occurs with early bowel obstruction, gastroenteritis, diarrhea

4 (Colorectal cancer in women is common in the United States; approximately 68,000 women are diagnosed each year. In the early stages, symptoms of cancer of the colon are vague or absent. Malignancy means a tendency to progress in virulence; a localized tumor usually is benign. Colorectal cancer is more common in men than women.)

A 66-year-old woman who has a history of a 30-pound weight loss in 3 months, as well as periods of constipation and diarrhea, is diagnosed with cancer of the colon. The nurse should incorporate into the client's teaching plan that malignant tumors of the colon and rectum are: 1 Easily detected. 2 Usually localized. 3 Found more frequently in women than in men. 4 Among the third most common cause of cancer in women.

1 (AF can be chronic or intermittent. Note the wavy baseline with uncoordinated atrial electrical activity and irregular ventricular rhythm. AF clients who have valvular disease are particularly at risk for venous thromboembolism (VTE). Symptoms depend upon the ventricular rate and, if rapid, the client can complain of fatigue, weakness, shortness of breath, dizziness, anxiety, syncope, palpitations, chest discomfort, and hypotension. Clients should be monitored carefully for these complications. Some clients can be asymptomatic. VT is a rapid ventricular rate typically between 100 and 250 beats/minute and characterized by wide bizarre "QRS" complexes. Clients exhibiting junctional tachycardia may have no P waves or inverted P waves and a rate greater than 100. SVT involves the rapid stimulation of atrial tissue at a rate of 150 to 250 beats/min in adults. During SVT, P waves may not be visible, especially if there is a 1:1 conduction with rapid rates, because the P waves are embedded in the preceding T wave. SVT may occur in healthy young people, especially women.)

A client comes to the emergency room (ER) complaining of weakness, dizziness, and difficulty breathing. The nurse performs an electrocardiogram (ECG) and notices this arrhythmia. Which arrhythmia is the client exhibiting? 1 Atrial fibrillation (AF) 2 Ventricular tachycardia (VT) 3 Junctional tachycardia 4 Supraventricular tachycardia (SVT)

1 (Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells.)

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. When describing the purpose of this drug to the client, the nurse explains that it: 1 Prevents extension of the clot 2 Reduces the size of the thrombus 3 Dissolves the blood clot in the vein 4 Facilitates absorption of red blood cells

2 (A PVC is a contraction originating in an ectopic focus in the ventricles; it is characterized by a premature, wide, distorted QRS complex with the P wave and PR interval buried in the distorted QRS complex, resulting in an irregular rhythm. (1) Irregular rhythm, abnormal shaped P wave, and normal QRS occur with a premature atrial complex. (3) Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS occur with sinus tachycardia. (4) Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide, distorted QRS occur with ventricular tachycardia.)

A client experiences crushing chest pain and is brought to the emergency department. When assessing the ECG tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the electrocardiogram support this conclusion? 1 Irregular rhythm, abnormal shaped P wave, and normal QRS 2 Irregular rhythm, absence of a P wave, wide, and distorted QRS 3 Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS 4 Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide, distorted QRS

3 (A brick red stoma indicates adequate vascular perfusion. A pink, gray, or dark purple color indicates inadequate perfusion of the stoma. Topics)

A client had a colon resection and formation of a colostomy two days ago. What color does the nurse expect the stoma to be when assessing its viability? 1 Pink 2 Gray 3 Brick red 4 Dark purple

2 (Because the client is out of bed more at home and the leg used for the donor graft is in the dependent position, edema of this extremity usually increases. The internal mammary artery is the graft of choice and was probably used in the first CABG procedure, necessitating retrieval of a vessel from the leg. Serosanguinous drainage may persist after discharge. Mild incisional pain and tenderness may persist longer than 3 to 4 weeks because it takes 6 to 12 weeks for the sternum to heal. Extreme fatigue and a mild fever are not expected; these are associated with postpericardiotomy syndrome and should be reported to the health care provider immediately.)

A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home? 1 No further drainage from the incisions 2 Increased edema in the leg that provided the donor graft 3 Mild incisional pain and tenderness for three to four weeks 4 Extreme fatigue and a mild fever occurring for several week

3 (When ambulating a client, the nurse walks on the client's stronger or unaffected side. This provides a wide base of support and therefore increases stability during the phase of ambulation that calls for weight bearing on the affected side as the unaffected limb moves forward. Behind or in front of the client positions tend to change the center of gravity from directly above the feet and may cause instability. On the client's right side will not support the client as the strong leg moves forward and weight bearing is on the affected side.)

A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? 1 Behind the client 2 In front of the client 3 On the client's left side 4 On the client's right side

4 (The drug will be given routinely to maintain a continuous therapeutic blood level to keep the terminally ill client comfortable. Addiction is not a major concern for the terminally ill client. The client should not have to request this medication; it should be given regularly. Morphine is not administered intermittently; usually, it is prescribed in liquid form and is taken orally when administered in the home.)

A client in a hospice home care program is experiencing severe pain. Morphine (MS Contin) has been prescribed for pain management. Which information should the nurse plan to explain to the client in preparation for this pain management regimen? 1 Drug addiction is a concern with this drug 2 Request the medication before the pain becomes severe 3 Intermittent administration of the drug is possible after an intermittent lock is inserted 4 Dosages of the drug will be given automatically at regular intervals around the clock

3 (Baseline pulse and respiratory rates will aid in monitoring treatment efficacy and help identify concurrent problems, such as heart failure and dysrhythmias. Collecting urine and blood samples is not the priority at this time; this may be done later. Bed rest is appropriate; however, positioning the client in the supine position may precipitate respiratory distress; a semi-Fowler to high-Fowler position should be maintained to facilitate respirations.)

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. In response to the clinical manifestations, the nurse should: 1 Obtain a glucose blood sample 2 Collect urine and blood samples 3 Assess the client's pulse and respirations 4 Place the client on bed rest in the supine position

1 (Circulatory collapse can be caused by exposure to an infection or a cold or by overexertion of a client with chronic adrenocortical insufficiency (Addison disease). Roommates with a fractured leg, a brain attack, or cholecystitis are appropriate room assignments because they are not communicable infections.)

A client is admitted with a diagnosis of chronic adrenal insufficiency. When assigning a room, which roommate should be avoided because of the newly admitted client's condition? 1 Young adult client with pneumonia 2 Adolescent client with a fractured leg 3 Older adult client who had a brain attack 4 Middle-aged client who has cholecystitis

1 2 5 (Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.)

A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply. 1 Fatigue 2 Dry skin 3 Insomnia 4 Intolerance to heat 5 Progressive weight gain

3 (Probenecid results in better use of penicillin by delaying the excretion of penicillin through the kidneys. Penicillin destroys Treponema pallidum during all stages of its development; probenecid delays the excretion of penicillin. Probenecid does not treat urethritis. Probenecid does not prevent allergic reactions.)

A client is receiving penicillin G and probenecid for syphilis. What rationale should the nurse give for the need to take these two drugs? 1 Each drug attacks the organism during different stages of cell multiplication. 2 The penicillin treats the syphilis, whereas the probenecid relieves the severe urethritis. 3 Probenecid delays excretion of penicillin, thus maintaining blood levels for longer periods. 4 Probenecid decreases the potential for an allergic reaction to penicillin, which treats the syphilis

3 (Supporting the head with the hands when changing position relieves tension on the incision and limits the risk of dehiscence. Coughing should be avoided during the early postoperative period to prevent trauma to the operative site. Performing range-of-motion exercises of the head and neck should be avoided until advised by the health care provider, usually after sutures or skin clips have been removed. Pressure against the operative area is not necessary to promote integrity of the incision, and it may inhibit swallowing.)

A client is scheduled to have a thyroidectomy for cancer of the thyroid. What specific instruction about postoperative care should the nurse provide the client during preoperative teaching? 1 Cough and deep breathe every hour. 2 Perform range-of-motion exercises of the head and neck. 3 Support the head with the hands when changing position. 4 Apply gentle pressure against the incision when swallowing.

2 5 (Weight gain is a sign of heart failure, which may develop with the persistent tachycardia that is present with hyperthyroidism; this should be reported to the health care provider immediately. Pedal edema is a sign of heart failure, which may develop with the persistent tachycardia that is present with hyperthyroidism; this should be reported to the health care provider immediately. Diaphoresis, flushed skin, and nervousness are expected to occur with hyperthyroidism and need not be reported immediately.)

A client is taking an antithyroid medication for hyperthyroidism. The nurse provides education about serious health problems that may develop if the medication is not effective and tachycardia continues. The nurse instructs the client to seek medical attention immediately if any of the problems occur. Which should be included in the teaching? Select all that apply. 1 Diaphoresis 2 Weight gain 3 Flushed skin 4 Nervousness 5 Pedal edema

3 4 5 (Weakness occurs because of muscle wasting due to the catabolic effects of cortisol. Hypokalemia may also cause weakness; potassium is lost in the urine as sodium is retained. Cortisone increases sodium and water retention, but does not cause oliguria; glucose levels also increase which, if extreme, will cause polyuria. An accumulation of adipose tissue occurs in the face (moon face), trunk (truncal obesity), and cervical area (buffalo hump). Weight gain occurs because of increased appetite and fluid retention; one liter of fluid is equal to 2.2 pounds. The appetite usually increases, not decreases. Cortisone increases blood glucose levels, which, if extreme, will cause lethargy, not nervousness.)

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply. 1 Oliguria 2 Anorexia 3 Weakness 4 Moon face 5 Weight gain 6 Nervousness

3 (Self-splinting results in shallow breathing, which does not aerate the lungs adequately, particularly the lower right lobe. The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the physician then removes the tube. The nurse does not change the dressing in the immediate postoperative period; the client's respiratory status takes priority. The client will be nothing by mouth immediately after surgery.)

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the priority nursing action is: 1 Irrigating the T-tube every hour 2 Changing the dressing every two hours 3 Encouraging coughing and deep breathing 4 Promoting an adequate fluid and food intake

1 (The nurse must analyze the feelings that are implied in the client's question and reflect these to help the client verbalize and explore them; the focus is on collecting more data. No data presented at this time suggest that a referral to a psychiatric nurse is warranted; this also cuts off communication when the client has expressed a need. The nurse is avoiding the responsibility to assist the client. Although providing information that the client is correct in being especially careful in these areas may be true, it does not respond to the feelings implied in the client's comment. Suggesting that the client discuss follow-up care with the health care provider and the dietician is avoiding the responsibility of helping the client explore feelings; it cuts off communication.)

A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial response? 1 Focus on the client's feelings by exploring the reason why the question was asked. 2 Explain that it is all right to be frightened and refer the client to the psychiatric nurse. 3 Provide information that the client is correct in being especially careful in these areas. 4 Suggest that the client discuss follow-up care with the health care provider and the dietitian.

4 (Doxorubicin is cardiotoxic, which is manifested by transient ECG abnormalities. Alopecia is an expected side effect of doxorubicin, not a toxic effect.)

A client who has been diagnosed with acute lymphocytic leukemia will be receiving doxorubicin (Adriamycin) infusions as part of a chemotherapy regimen. The nurse monitors the client for signs and symptoms of doxorubicin toxicity. What clinical finding indicates that toxicity has occurred? 1 Alopecia 2 Dyspnea 3 Metallic taste to food 4 Abnormalities in cardiac rhythm

3 5 (Increased serum calcium comes from bone demineralization, which results in pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles). Convulsions are not a sign of hypercalcemia; convulsions can occur with hypocalcemia, hypernatremia, and hyponatremia. Muscle spasms are not a sign of hypercalcemia; muscle spasms can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; paresthesias are associated with hypocalcemia and hyperkalemia.)

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply. 1 Convulsions 2 Muscle spasms 3 Deep bone pain 4 Tingling of extremities 5 Depressed deep tendon reflexes

4 (Dialysate is introduced into the peritoneal cavity where fluids, electrolytes, and wastes are exchanged through the peritoneal membrane. Hemodialysis is not necessary with continuous ambulatory peritoneal dialysis. The client can dialyze alone in any location without the need for continuous technical supervision. About 2 liters, not a quarter of a liter, of dialysate are maintained intraperitoneally and can be instilled and drained by the client.)

A client who is to begin continuous ambulatory peritoneal dialysis asks the nurse what this entails. What information should the nurse include when answering the client's question? 1 Hemodialysis and peritoneal dialysis will be done together. 2 Peritoneal dialysis is performed in an ambulatory care clinic. 3 About a quarter of a liter of dialysate is maintained in the peritoneal cavity. 4 Constant contact is maintained between the dialysate and the peritoneal membrane.

4 (Alkylating agents, of which nitrogen mustard is one, combine with DNA strands and interfere with cell replication. Some chemotherapeutic drugs are believed to act by interfering with cellular protein synthesis, but nitrogen mustard does not. Inhibiting the synthesis of purine and pyrimidine is the mechanism of action of antimetabolites. Antibiotics, not nitrogen mustard, used in cancer chemotherapy are believed to act by binding with DNA to interfere with RNA production.)

A client who is to receive nitrogen mustard as part of a drug protocol for cancer asks how this drug works in the body. Before responding in language the client can understand, the nurse considers the actions of nitrogen mustard, which include: 1 Interference of the cellular protein synthesis 2 Inhibition of the synthesis of purine and pyrimidine 3 Binding with DNA to interfere with RNA production 4 Combining with DNA strands and interfering with cell replication

4 (Clients with Cushing syndrome or those who are receiving cortical hormones must limit their intake of sodium and increase their intake of potassium because the kidneys are retaining sodium and excreting potassium. Although sodium retention causes fluid retention and weight gain, the need for increased potassium must be considered as well. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.)

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. The nurse explains that: 1 The client will gain excessive weight if sodium is not limited 2 An inadequate intake of potassium contributed to the disease 3 This type of diet increases emotional stability 4 Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium

3 (Both digoxin and verapamil decrease cardiac impulse conduction, with resultant depression of the myocardium; verapamil decreases conduction at the sinoatrial (SA) and atrioventricular (AV) nodes, which may cause bradycardia, AV block, and cardiac arrest. Digoxin and verapamil together do not cause agitation. Side effects of verapamil include fatigue and depression, not agitation. Digoxin and verapamil do not influence the reflexes of the body. Digoxin and verapamil do not influence respirations.)

A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for: 1 Physical agitation 2 Reflex stimulation 3 Myocardial depression 4 Respiratory stimulation

1234(The blood to be infused must be typed and crossmatched with the client's blood to ensure that the blood is compatible and will not cause a transfusion reaction. Flushing the line will prevent an air embolism, and normal saline is used because it is compatible with blood. Two nurses must check the blood and the client's identification before blood administration can begin. Starting the transfusion at a slow rate provides time to identify that a transfusion reaction is developing before too much blood is administered.)

A client with a gastric hemorrhage is to receive 2 units of whole blood. List the nurse's activities in the order that they should be performed when administering a blood transfusion. 1. Verify that typing and crossmatching of the prescribed blood has occurred. 2. Flush the infusion tubing with normal saline. 3. Ask another nurse to check the blood at the client's bedside. 4. Run the blood at a slower rate during the first 10 minutes of the transfusion.

3 (A pseudocyst of the pancreas is an abnormally dilated space that contains blood, necrotic tissue, and enzymes, and is surrounded by connective tissue. Malignant growth, pocket of undigested food particles, and sack filled with fluid and pancreatic enzymes are incorrect definitions of a pseudocyst.)

A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" What information should the nurse include in a response to this question? 1 Malignant growth 2 Pocket of undigested food particles 3 Dilated space of necrotic tissue and blood 4 Sack filled with fluid and pancreatic enzymes

1 2 3 (Signs and symptoms of digoxin toxicity include: bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, ECG findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of the diuretic furosemide; a pulse rate of 64 beats per minute is an acceptable rate when a client is receiving digoxin.)

A client with heart failure is receiving digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). The nurse will assess for which signs and symptoms of digoxin toxicity? Select all that apply. 1 Nausea 2 Yellow vision 3 Irregular pulse 4 Increased urine output 5 Pulse rate of 64 beats per minute

4 (Having a normally functioning thyroid (euthyroid) decreases the risk of thyrotoxic crisis after surgery. Ideally the client should be normotensive; some clients are slightly hypertensive because of the increased metabolic rate associated with hyperthyroidism. Weighing in the expected range may be impossible; the client may be underweight because of the increased metabolic rate associated with hyperthyroidism. The client should be in a positive nitrogen balance to promote wound healing.)

A client with hyperthyroidism refuses radioactive iodine therapy and a subtotal thyroidectomy is scheduled. The nurse reviews the preoperative plan of care and questions which prescription? 1 High-protein, high-carbohydrate diet 2 Iodine preparations 3 Antithyroid drugs 4 Drugs to increase the blood pressure

1 (The anticholinergic activity of each drug is magnified, and adverse effects such as paralytic ileus may occur. Hypotension, not hypertension, occurs with anticholinergic medications. Dryness of the mouth, not increased salivation, occurs with anticholinergic medications. Decreased, not increased, perspiration occurs with anticholinergic medications.)

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The practitioner prescribes the anticholinergic medication benztropine (Cogentin) 2 mg daily. What should the nurse assess the client for daily when administering these medications together? 1 Constipation 2 Hypertension 3 Increased salivation 4 Excessive perspiration

4 (As fluid is administered intravenously or retained by the kidneys, the intravascular fluid volume increases, resulting in increased preload and afterload. Increased, not decreased, afterload will cause an increase in the pulmonary artery wedge pressure. Afterload is the peripheral resistance against which the left ventricle must pump. A decreased heart rate will not increase pulmonary artery wedge pressure. After a pulmonary artery wedge pressure reaches 20 mm Hg, the stroke volume does not increase significantly.)

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider the most likely reason for this change? 1 Decreased afterload 2 Decreased heart rate 3 Increased stroke volume 4 Increased intravascular volume

1 (Because the client has type 1 diabetes, it is essential that the blood glucose level be determined before meals to evaluate the level of control of diabetes and the possible need for insulin coverage. To prevent flexion contractures of the hip, the client should not sit for a prolonged time; this is not the priority. Raising the head of the bed flexes the hips, which may result in hip flexion contractures; this is not the priority. Ensuring the client's residual limb is elevated may result in a hip flexion contracture and should be avoided.)

A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner? 1 Checking the client's serum glucose level 2 Assisting the client out of bed into a chair 3 Placing the client in the high-Fowler position 4 Ensuring the client's residual limb is elevated

4 (Allopurinol can potentiate the effect of oral hypoglycemics, causing hypoglycemia; the blood glucose level should be monitored more frequently. NSAIDs can be taken concurrently with Allopurinol. A daily fluid intake of 2500 to 3000 mL will limit the risk of developing renal calculi. Allopurinol should be taken with milk or food to decrease gastrointestinal irritation.)

A client with type 2 diabetes develops gout, and allopurinol (Zyloprim) is prescribed. The client is also taking metformin (Glucophage) and an over-the-counter nonsteroidal antiinflammatory drug (NSAID). When teaching about the administration of allopurinol, what should the nurse instruct the client to do? 1 Decrease the daily dose of NSAIDs. 2 Limit fluid intake to one quart a day. 3 Take the medication on an empty stomach. 4 Monitor blood glucose levels more frequently.

4 (The client is experiencing the Somogyi effect. It is a paradoxical situation in which sudden decreases in blood glucose are followed by rebound hyperglycemia. The body responds to the hypoglycemia by secreting glucagon, epinephrine, growth hormone, and cortisol to counteract the low blood sugar; this results in an excessive increase in the blood glucose level. It most often occurs in response to hypoglycemia when asleep. The health care provider may choose to decrease the insulin dose and then reassess the client. Giving the client 8 oz of orange juice will increase further the serum glucose level and is contraindicated. Increasing the insulin dose at bedtime will further worsen the problem. Encouraging the client to eat smaller, more frequent meals will not address the hypoglycemia and rebound hyperglycemia that occurs when sleeping. However, a bedtime snack may help minimize this event.)

A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs? 1 Give the client 8 oz of orange juice. 2 Seek a prescription to increase the insulin dose at bedtime. 3 Encourage the client to eat smaller, more frequent meals. 4 Collaborate with the health care provider to alter the insulin prescription.

2 (Active immunity occurs when the individual's cells produce antibodies in response to an agent or its products; these antibodies will destroy the agent (antigen) should it enter the body again. Antigens do not fight antibodies; they trigger antibody formation that in turn attacks the antigen. Antigens are foreign substances that enter the body and trigger antibody formation. Sensitized lymphocytes do not act as antibodies.)

A client, who has been living in another country for 10 years, is undergoing diagnostic testing to identify the causative organisms of the infection that has been acquired. When caring for this client, the nurse recalls that active immunity occurs when: 1 Protein antigens are formed in the blood to fight invading antibodies 2 Protein substances are formed within the body to neutralize antigens 3 Blood antigens are aided by phagocytes in defending the body against pathogens 4 Sensitized lymphocytes from an immune donor act as antibodies against invading pathogens

3 (Diarrhea is a possible side effect that can be related to superinfection or to destruction of bacterial flora in the intestine; it can lead to fluid and electrolyte imbalance. Ampicillin is absorbed best when taken with water on an empty stomach. Although storage in an airtight container is necessary, protection from light is not. A culture generally is not repeated unless the client's condition indicates that the medication was ineffective.)

A health care provider prescribes ampicillin for a client with an infection. What information should the nurse include in the teaching plan about this medication? 1 Take the ampicillin with meals. 2 Store the ampicillin in a light-resistant container. 3 Notify the health care provider if diarrhea develops. 4 Continue the drug until a negative culture is obtained.

3 (Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.)

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? 1 Fluid loss 2 Glycosuria 3 Kussmaul respirations 4 Increased blood glucose level

1 (There are increased levels of steroids and aldosterone causing sodium and water retention in clients with Cushing syndrome. Hypertension, not hypotension, is expected because of sodium and water retention. The extremities will be thin; subcutaneous fat deposits occur in the upper trunk, especially the back between the scapulae. Hyperglycemia, not hypoglycemia, occurs because of increased secretion of glucocorticoids. *Hyperglycemia is sustained and not restricted to the morning hours.)

A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify? 1 Retention of sodium and water 2 Hypotension and a rapid, thready pulse 3 Increased fatty deposition in the extremities 4 Hypoglycemic episodes in the early morning

1 3 6 (As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost through urination, dehydration occurs, resulting in dry mucous membranes and poor skin turgor. Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose levels are not affected. Loss of fluid may decrease the blood pressure because fluid is lost from the intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.)

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply. 1 Excessive thirst 2 Increased blood glucose 3 Dry mucous membranes 4 Increased blood pressure 5 Decreased serum osmolarity 6 Decreased urine specific gravity

3 (Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect of increased adrenaline released from the adrenal medulla during stress; it is not specific to hypertension.)

A nurse is assessing a client with the diagnosis of primary hypertension. What clinical finding does the nurse identify as an indicator of primary hypertension? 1 Mild but persistent depression 2 Transient temporary memory loss 3 Occipital headache in the morning 4 Cardiac palpitation during periods of stress

2 3 (Signs and symptoms of thrombophlebitis include pain, redness, swelling, and heat. It is associated with the formation of a clot (thrombosis). A marked increase in blood flow (hyperemia) is associated with the inflammatory response; it causes heat at the site of a thrombophlebitis. Itching is not a symptom of thrombophlebitis. Although swelling accompanies thrombophlebitis, it is not pitting edema. Thrombophlebitis usually is located in the area of the calf, in a deep vein, not over a bony prominence at the ankle.)

A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? Select all that apply. 1 Pruritus of the calf 2 Tender area on the leg 3 Warm area over the calf 4 Pitting edema of the ankle 5 Reddened area at the ankle

4 (Hydrocortisone succinate is a glucocorticoid. A client undergoing bilateral adrenalectomy must be given adrenocortical hormones so that adjustment to the sudden lack of these hormones that occurs with this surgery can take place Methimazole is used to treat a client with hyperthyroidism, not a client with a bilateral adrenalectomy. Because the surgery involves the adrenal glands, not the pituitary gland, secretion of pituitary hormones will not be affected. Regular insulin is not necessary. Insulin is produced by the pancreas, and its function is not altered by this surgery.)

A nurse is caring for a client who is scheduled for a bilateral adrenalectomy. Which medication should the nurse expect to be prescribed for this client on the day of surgery and in the immediate postoperative period? 1 Methimazole (Tapazole) 2 Pituitary extract (Pituitrin) 3 Regular insulin (Novolin R) 4 Hydrocortisone succinate (Solu-Cortef)

4 (Lack of mineralocorticoids (aldosterone) leads to loss of sodium ions in the urine and subsequent hyponatremia. Potassium intake is not encouraged; hyperkalemia is a problem because of insufficient mineralocorticoids. Increasing protein is needed to heal the adrenal tissue and thus cure the disease caused by idiopathic atrophy of the adrenal cortex; tissue repair of the gland is not possible. Vitamins are not directly energy-producing, nor will they help the client gain weight.)

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan as a means of encouraging this client to modify dietary intake? 1 Increased amounts of potassium are needed to replace renal losses. 2 Increased protein is needed to heal the adrenal tissue and thus cure the disease. 3 Supplemental vitamins are needed to supply energy and assist in regaining the lost weight. 4 Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

1 (Acromegaly is caused by increased secretion of growth hormone in adults after full growth and epiphyseal closure; it causes enlargement of bones and soft tissue of the lower jaw, cheeks, hands, and feet. Increased growth hormone causes gigantism in children BEFORE epiphyseal closure of long bones.)

A nurse is caring for an adult client with acromegaly. What clinical manifestation does the nurse expect the client to exhibit? 1 Prominent jaw 2 Decreased pulse 3 Increased height 4 Increased sodium

3 (Thromboangiitis obliterans is characterized by vascular inflammation in the hands and feet, leading to thrombus formation. As a result of impaired circulation, burning pain and intermittent claudication occur. General blanching of the skin, easy fatigue of extremities, and presence of Homans sign when ambulating are not related to thromboangiitis obliterans.)

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms most likely are to be associated with this disorder? 1 General blanching of skin 2 Easy fatigue of extremities 3 Burning pain after exposure to cold 4 Presence of Homans sign when ambulating

2 3 1 5 4 (Washing the hands prevents cross contamination. Rotating the insulin vial distributes the drug evenly throughout the vial. Wiping the seal on the insulin vial prevents contamination of the needle and the fluid. Instilling air into the vial increases the pressure in the closed space so that the correct amount of fluid finally can be withdrawn.)

A nurse is preparing to administer insulin to a client with diabetes. In which order should the nurse perform the actions associated with insulin administration? 1. Wipe the top of the insulin vial with an alcohol swab 2. Wash hands with soap and water 3. Rotate the vial of insulin between the palms of the hands 4. Withdraw the correct amount of insulin from the inverted vial 5. Instill air into the vial of insulin equal to the desired dose

1 2 4 (Ulceration of the intestinal mucosa commonly occurs, causing blood loss and anemia. The inflammatory process tends to increase peristalsis, causing diarrhea, electrolyte imbalances, and weight loss. The inflammatory process tends to increase peristalsis, causing abdominal cramping and diarrhea. Coughing up blood from the respiratory tract (hemoptysis) is not associated with colitis. A decreased number of white blood cells (leukopenia) is not associated with colitis.)

A nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. What clinical findings are associated with this disorder? Select all that apply. 1 Anemia 2 Diarrhea 3 Hemoptysis 4 Abdominal cramps 5 Decreased white blood cells

2 (Constriction of the peripheral blood vessels and the resulting increase in blood pressure impair circulation and limit the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels.)

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group? 1 Constriction of the superficial vessels dilates the deep vessels. 2 Constriction of the peripheral vessels increases the force of flow. 3 Dilation of the superficial vessels causes constriction of collateral circulation. 4 Dilation of the peripheral vessels causes reflex constriction of visceral vessels.

2 3 4 5 1 (Air should be injected into the air space of the intermediate-acting insulin vial before short-acting insulin is drawn into the syringe; the needle should not touch the insulin. The nurse should inject the amount of air into the short-acting insulin vial equivalent to the volume to be withdrawn to prevent negative pressure that can make withdrawal difficult. The short-acting insulin should be withdrawn first to prevent possible contamination of the vial with the intermediate-acting insulin, which would cause a delay in onset time of the short-acting insulin. The intermediate-acting insulin should be drawn up after the short-acting insulin to prevent contamination of the short-acting insulin. Gloves are not needed to draw up insulin, but should be worn for its administration to the client.)

A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them. 1. Don a pair of clean gloves. 2. Put air into the intermediate-acting insulin vial. 3. Put air into the short-acting insulin vial. 4. Withdraw the prescribed amount of short-acting insulin. 5. Withdraw the prescribed amount of intermediate-acting insulin.

4 (The symptoms indicate possible Hodgkin's lymphoma, so diagnostic testing will likely include computed tomography (CT scan) and a lymph node biopsy. IV fluids, antibiotic therapy, oxygenation therapy, and nutritional therapy are not requirements at this point in treatment.)

An 11 year-old girl is admitted with enlarged supraclavicular lymph nodes, fatigue, and low-grade fever. She also has a persistent nonproductive cough. In light of these findings, the nurse knows to gear education toward preparation for: 1 IV fluids and nutritional therapy 2 Bloodwork and oxygenation therapy 3 Intravenous fluids and antibiotic therapy 4 Computed tomography and lymph node biopsy

1 2 5 (Left-sided heart failure causes impaired tissue perfusion, pulmonary congestion, and pulmonary edema, which also causes signs and symptoms such as crackles and dyspnea. Decreased cardiac output causes decreased blood flow to major body organs, especially the kidneys. (oliguria) Peripheral edema and jugular distention are signs of right sided congestive heart failure.)

An 83-year-old client is diagnosed with left-sided congestive heart failure. Which assessment findings should the nurse expect to find on this client? Select all that apply. 1 Dyspnea 2 Crackles 3 Peripheral edema 4 Jugular distention 5 Cool extremities

2 3 5 1 4 Tuberculosis is transmitted via microorganisms that travel with air currents. The client should be placed in a room that has at least six exchanges of air per hour and is ventilated to the outside. Care givers should wear a high-efficiency particulate air respirator. A chest x-ray study is the quickest way to determine the presence of suspicious lesions in the lung. A PPD test can be read in 48 to 72 hours. A positive culture may not develop for 3 to 6 weeks. The Department of Health should be notified when the diagnosis of tuberculosis is confirmed.

An older adult, who alternately lives in a homeless shelter and on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and prescribes a purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed. 1. Obtain a sputum specimen. 2. Institute airborne precautions. 3. Have a chest x-ray performed. 4. Notify the Department of Health. 5. Perform a PPD intradermal skin test.

3 (The usual dose of IM haloperidol is 2 to 5 mg every two to four hours; the prescribed dose is above the maximum limit and should be questioned. Giving haloperidol 100 mg IM stat is unsafe. It is the nurse's responsibility to know the correct dose of a medication and to question a prescription that is more or less than the accepted limits. Haloperidol is an antipsychotic, not an antidepressant; antidepressants take two to three weeks to achieve a therapeutic effect. Haloperidol may be administered either orally or intramuscularly.)

Haloperidol (Haldol) 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered and agitated after a street brawl. The nurse reviews the prescription and concludes that: 1 The medication is appropriate and should be given as prescribed 2 The medication is inappropriate because it takes one week for antidepressants to be effective 3 The dose is more than recommended 4 The route of administration is incorrect

thrombophlebitis

High-risk of developing this during pregnancy and immediate post-partum period. Inflammation of vein associated w/ formation of a thrombus or blood clot. Other risk factors: prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration, and CHF. S/s: pain in the calf, localized edema of one extremity, positive Homans' sign (pain in calf when foot is dorsiflexed). Treatment: bed rest and elevation of extremity, anticoagulant (heparin).

3 4 5 (The children are at an increased risk because the client's spouse has TB; the children should be screened as members of the household. The positive skin test indicates that the client has been exposed to the bacilli and developed antibodies, not necessarily the disease itself; further diagnostic studies are indicated. Both wine and aged cheese contain tyramine and histamine, which when taken concurrently with INH can cause headache, flushing, and a drop in blood pressure; these should be avoided when taking INH. Pyridoxine (vitamin B6) should be taken to prevent neuritis, which is associated with INH. The prophylactic drug therapy will be continued for 6 to 12 months.)

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? Select all that apply. 1 "I plan to start taking vitamin B6 (NesTrex) with breakfast." 2 "I'll still be taking this drug six months from now." 3 "I sometimes allow our children to sleep in our bed at night." 4 "I know I also have tuberculosis because the skin test was positive." 5 "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

1 (The underlying rhythm is identified first. Following this step, the dysrhythmia that is occurring to disrupt the underlying rhythm is then determined. A PAC is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the sinoatrial (SA) node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute.)

The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats/min and the blood pressure is normal. The nurse interprets this rhythm as: 1 Sinus rhythm with premature atrial contractions (PACs). 2 Normal sinus rhythm. 3 Sinus tachycardia. 4 Sinus bradycardia with premature ventricular contractions (PVCs).

1 (The concentration of glucose in the solution (20% to 25%) is a rich culture medium for bacterial and fungal growth. Hepatitis is not associated with total parenteral nutrition. Anorexia often is present before the medical decision to begin total parenteral nutrition; it is not a complication. Dysrhythmias are not related directly to total parenteral nutrition but rather to concomitant hypokalemia, which can occur if potassium is not added to the solution.)

The nurse assesses a client who is receiving total parenteral nutrition for the specific complication of: 1 Infection 2 Hepatitis 3 Anorexia 4 Dysrhythmias

2 3 4 (Headache is a neuroglycopenic response directly related to brain glucose deprivation. **Tachycardia occurs with hypoglycemia because of a neurogenic adrenergic response; it is a sympathetic nervous system response precipitated by a low blood glucose level. Cool, clammy skin is a neurogenic cholinergic response; it is a sympathetic nervous system response precipitated by a low serum glucose level. Vomiting occurs with hyperglycemia because of the effects of metabolic acidosis. Increased respirations are a sign of hyperglycemia and are related to metabolic acidosis; this is a compensatory response in an attempt to blow off carbon dioxide and increase the pH level.)

The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? Select all that apply. 1 Vomiting 2 Headache 3 Tachycardia 4 Cool clammy skin 5 Increased respirations

1 2 4 (Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. Alcoholism can cause relaxation of the lower esophageal sphincter (LES) and upper esophageal sphincter (UES), causing risk for aspiration and potentially causing the bronchitis, which can exacerbate the hiatal hernia. Inflammation of the bronchi will not weaken the diaphragm. Esophagitis does not cause a hiatal hernia.)

The nurse is caring for a 76-year-old obese client with a history of epigastric distress, esophageal burning, binge drinking, and frequent episodes of bronchitis. A diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1 Aging 2 Obesity 3 Bronchitis 4 Alcoholism 5 Esophagitis

2 (The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation. If a premature ventricular contraction strikes on the P wave, it will not cause ventricular fibrillation; the P wave represents atrial contraction. The P-R interval represents the time it takes the impulse to travel from the sinoatrial (SA) node to the ventricular musculature. The QRS complex is the term used to represent the entire phase of ventricular contraction.)

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle? 1 P wave 2 T wave 3 P-R interval 4 QRS complex

1 2 5 Anorexia, nausea, and vomiting occur because of pressure on the hypothalamus. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. 1 Vomiting 2 Irritability 3 Hypotension 4 Increased respirations 5 Decreased level of consciousness

3 (Injury and pressure at the nerve roots produce pain. Injury at T6 and T7 is too low to cause paralysis of the respiratory muscles; control of respirations is in the medulla and the cervical plexus (phrenic nerve).With complete crushing at the T6 and T7 level, there is no pain sensation in parts distal to the injury. Initially, paralysis is flaccid; spasticity is a later manifestation.)

The nurse is caring for a client whose vertebral column at the level of T6 and T7 was completely crushed and whose left leg was amputated traumatically above the knee. The nurse expects what clinical assessment finding? 1 Difficulty breathing 2 Discomfort in the residual limb 3 Pain at the level of compression 4 Spastic paralysis of the extremities

3 (Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goosebumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. The client being upright on a tilt table is not involved in the autonomic hyperreflexia phenomenon. The Myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the autonomic hyperreflexia phenomenon.)

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. The nurse recalls that the most common cause of this response is: 1 Hemodynamic changes related to tilt table positioning 2 Deteriorating myelin sheath 3 Distended large intestine 4 Crushed spinal cord

1 5 (Edema results as fluid is retained because of the increased secretion of antidiuretic hormone. ADH causes water retention, which dilutes serum electrolytes such as sodium, with a resultant hyponatremia. A decreased urine output occurs with SIADH because ADH causes reabsorption of fluid in the kidney glomeruli. The increased fluid volume associated with SIADH results in tachycardia, tachypnea, and crackles. ??? The increased fluid volume associated with SIADH results in hypertension, not hypotension.)

The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply. 1 Edema 2 Polyuria 3 Bradycardia 4 Hypotension 5 Hyponatremia

1 4 5 (Diabetes insipidus is a condition resulting in underproduction of antidiuretic hormone. The focus of care is on maintaining fluid and electrolyte balance. Oral fluids must be easily accessible at the bedside to balance urinary losses and prevent severe dehydration. The nurse monitors for, and reports, changes in neurological status associated with hypernatremia and high serum osmolality. Constipation and weight loss indicate fluid volume deficit and must be reported. Hypotentsion and tachycardia are signs of impending shock. Massive polyuria results in dilute urine. Decreasing urine specific gravity must be reported. Demaclocycline decreases the renal response to antidiuretic hormone (ADH) or endogenous vasopressin. In diabetes insipidus, ADH production is decreased. The primary pharmacologic treatment for diabetes insipidus, then, is replacement of ADH with an exogenous vasopressin, such as desmopressin acetate (DDAVP).)

The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply. 1 Providing adequate fluids within easy reach 2 Reporting an increasing urine specific gravity 3 Administering prescribed demeclocycline (Declomycin) 4 Assessing for and reporting changes in neurological status 5 Monitoring for constipation, weight loss, hypotension, and tachycardia

1 4 5 (Thirst (polydypsia) is associated with hyperglycemia. This is in response to the polyuria associated with hyperglycemia. A fruity odor to the breath is acetone on the breath reflective of the presence of ketones; ketones are a byproduct of fat metabolism in an attempt to meet energy needs because the body is unable to convert glucose to glycogen. Excessive urination occurs when fluid is lost along with glucose as it is excreted in the urine. Headache is associated with hypoglycemia because of central nervous irritation secondary to a low blood glucose level. Nervousness is associated with hypoglycemia and hyperglycemia because of central nervous system irritation.)

The nurse provides education related to manifestations of hyperglycemia to a client with type 1 diabetes. Which signs and symptoms identified by the client indicate that the teaching was effective? Select all that apply. 1 Thirst 2 Headache 3 Nervousness 4 Fruity breath odor 5 Excessive urination

3 (Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation. Bed rest supports venous stasis rather than the circulation of blood to damaged tissues.)

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response is based on the principle that bed rest: 1 Prevents the further aggregation of platelets 2 Enhances the peripheral circulation in the deep vessels 3 Decreases the potential for further dislodgment of emboli 4 Maximizes the amount of blood available to damaged tissues

4 (A pancreaticoduodenectomy leads to malabsorption because of impaired delivery of bile to the intestine; fat metabolism is interfered with, causing dyspepsia. These clients are anorexic, require small frequent meals, and should eat a high-calorie, high- protein, low-fat diet. High-calorie meals are needed for energy and to promote use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless direct extension occurs.)

To prepare a client for discharge, the nurse is providing dietary instructions to a client that had a pancreaticoduodenectomy (Whipple procedure). What should the nurse include in the instructions? 1 The surgery has established normal digestive processes; no dietary restrictions are needed 2 To prevent overworking the pancreas, follow a low-calorie diet 3 Because of compromised liver function, restrict protein intake 4 The surgery has interfered with the fat digestion mechanism; a low-fat diet is needed

1 (The nurse should avoid walking swiftly past the client because drafts or even slight air currents can initiate pain. The client may assume any position of comfort, but pressure on the face while in the prone position may trigger an attack. Although the procedure for oral hygiene may be modified, it is not discontinued. Massaging may trigger an attack and should be avoided.)

What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux? 1 Avoid walking swiftly by the client. 2 Keep the client in the prone position. 3 Discontinue oral hygiene temporarily. 4 Massage both sides of the face frequently.

1 2 3 (SLE is a chronic, autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension.)

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply. 1 Joint pain 2 Facial rash 3 Pericarditis 4 Weight gain 5 Hypotension

1 (Smoking is a major risk factor for cardiovascular disease and hypertension, major health problems of middle-age adults. Middle-age adults are not at greater risk for infection. Alcohol intake should be limited, but total abstinence is not required for prevention of health problems. HDL levels should be increased to help prevent cardiovascular disease.)

What is the priority when working with a group of middle-aged adult clients? 1 Cessation of smoking 2 Prevention of infection 3 Abstinence from alcohol 4 Decreasing high-density lipoproteins (HDL) levels

1 (Atropine is an anticholinergic drug that blocks the muscarinic effects of acetylcholine; it is used as an antidote to counteract excessive effects of anticholinesterase drugs, such as pyridostigmine (Mestinon), neostigmine (Prostigmin), or edrophonium chloride. Severe respiratory distress is a clinical manifestation of myasthenic crisis. Edrophonium chloride is a short-acting anticholinesterase drug; if it produces an increase in weakness, the client is in cholinergic crisis, not myasthenic crisis. Increasing the dose of a cholinergic, not an anticholinergic, medication is the intervention for myasthenic crisis.)

When caring for a person with myasthenia gravis, a nurse considers the differences between myasthenic and cholinergic crises. The nurse concludes that: Correct1 Atropine is used to treat cholinergic crisis 2 Severe respiratory distress occurs with cholinergic crisis 3 Edrophonium chloride (Tensilon) causes transitory worsening of myasthenic crisis 4 Increased doses of an anticholinergic drug will treat myasthenic crisis

2 5 ((2) Confusion is associated with hyponatremia. Cellular swelling and cerebral edema are associated with hyponatremia; as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells. (5) Poor tissue turgor is associated with hyponatremia; as extracellular sodium level decreases, cellular fluid becomes more concentrated, and in response more fluid is pulled into the cells. Thirst is a symptom of hypernatremia; it may indicate dehydration. Tachycardia is associated with hypovolemia, not hyponatremia. Pallor is not a sign of hyponatremia; it may indicate anemia.)

When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? Select all that apply. 1 Thirst 2 Confusion 3 Tachycardia 4 Pale coloring 5 Poor tissue turgor

3 (A supportive nursing environment is one that fosters and supports open, honest communication among all disciplines involved in a client's care. This demonstrates respect for the professional psychiatric nurses and their influence on client health care. A sufficient number of qualified nursing personnel is a requirement on any nursing unit and shows a commitment to client care but not necessarily support for the unit's nursing staff. A modern, well-equipped nursing unit shows a commitment to client care but not necessarily support for the unit's nursing staff. Recognition of professional levels of nursing care is likely to have a positive effect on nursing morale but does not necessarily foster a supportive nursing environment.)

Which outcome best demonstrates a health care institution's commitment to providing a supportive environment for its psychiatric nursing staff? 1 Psychiatric nursing units are well staffed with qualified personnel. 2 The psychiatric units are equipped with the most modern client care equipment. 3 Psychiatric nurses are regularly recognized for their contributions to client health care. 4 The psychiatric nursing staff is represented in each client's multidisciplinary health care team.

1 3 6 (Pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot. Warmth is related to vasodilation. Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease. Although some localized edema occurs, pitting edema does not occur in thrombophlebitis. Ecchymosis is a sign of bleeding; thrombophlebitis is caused by a clot.)

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply. 1 Pain in the calf 2 Intermittent claudication 3 Redness in the affected area 4 Pitting edema of the lower leg 5 Ecchymotic areas around the ankle 6 Localized warmth in the lower extremity

3 5 ((3) Maintaining a consistent acceptable blood glucose level will improve A1c results. (5) Because insulin is administered only as needed, the client will be able to exercise without having to increase the carbohydrate intake. Ketoacidosis may occur if the catheter becomes dislodged and the client does not receive insulin for hours. Insulin pumps can cause weight gain, not loss. An insulin pump is more expensive than subcutaneous insulin injections.)

he nurse is teaching a diabetic client about the advantages of using an insulin pump. What information should the nurse include? Select all that apply. 1 It prevents ketoacidosis 2 It helps cause weight loss 3 It can improve A1c levels 4 An insulin pump costs less than subcutaneous injections 5 Clients can exercise without eating more carbohydrates

myxedema

hyposecretion of thyroxine (T4) and T3 causing weakness and fatigue; increased sensitivity to cold, constipation, dry skin, unexplained weight gain, depression, facial edema, goiter, nonpitting puffy appearance