NUR114 Med Surgical

A 51 year old truck driver who smokes 2 packs of cigarettes per day and is 30 pounds overweight is diagnosed with a gastric ulcer. What content is most important for a nurse to include in discharge instructions?

#1 information about smoking cessation. -- Smoking has been associated with ulcer formation so stopping or decreasing the number of cigarettes smoked per day is important to teach regarding ulcer management. -- rationales incorrect answer choices: the diet should not be low residue, it should be reduce high fiber/high roughage and spicy foods. A low residue diet would be indicated for a client with IBD. Sodium and caloric intake are not a part of an ulcer management diet. Although a client does need teaching regarding weight reduction, this does not relate to ulcer management. Increasing milk in the diet would result in increased gastric acid production and would make ulcer worse.

A nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client? (a) coping skills; (b) exercise class; (c) grief management; or (d) social support.

(a) coping skills -- ineffective coping skills are characteristic of depression

A client is receiving metoprolol (Lopressor SR). What assessment is most important for the nurse to obtain? A) Temperature. B) Lung sounds. C) Blood pressure. D) Urinary output.

) Blood pressure. It is most important to monitor the blood pressure (C) of clients taking this medication because Lopressor is an antianginal, antiarrhythmic, antihypertensive agent. While (A and B) are important data to obtain on any client, they are not as important for a client receiving Lopressor as (C). Intake and output ratios and daily weights should be monitored while taking Lopressor to assess for signs and symptoms of congestive heart failure, but (D) alone does not have the importance of (C).

Following heparin treatment for a pulmonary embolism, a client is being discharged with a prescription for warfarin (Coumadin). In conducting discharge teaching, the nurse advises the client to have which diagnostic test monitored regularly after discharge? A) Perfusion scan. B) Prothrombin Time (PT/INR). C) Activated partial thromboplastin (APTT). D) Serum Coumadin level (SCL

) Prothrombin Time (PT/INR). When used for a client with pulmonary embolus, the therapeutic goal for warfarin therapy is a PT 1½ to 2½ times greater than the control, or an INR of 2 to 3 (B). A perfusion might be performed to monitor lung function, but not monthly (A). APTT is monitored for the client receiving heparin therapy (C). A blood level for Coumadin cannot be measured (D).

The health care provider prescribes digitalis / Digoxin for a client diagnosed with -CHF- congestive heart failure. Which intervention should the nurse implement prior to administrating digoxin?

**Assess the client's serum potassium level. -- Hypokalemia - reduced levels of potassium - will precipitate potassium toxicity in clients receiving digoxin. --- If client is a diabetic, and possibly receiving insulin, the serum glucose level would be monitored.

A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as a part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

**Reassess the client's mental status for thought processes and content. -- Do not argue with client or attempt to collaborate a change of mind.

A client with bipolar disorder on a mental health unit becomes loud and shouts at one of the nurses: "You fat tub of lard! Get something done around here!" What is the nurse's best initial response?

**Redirect the client's energy by asking him to tidy the recreation room. -- Distracting the client or redirecting his energy helps prevent further escalation of the inappropriate behavior. --Rationales for incorrect answer choices: 1. have the orderly escort client to his room - could result in escalating the abuse and unnecessarily involve another staff member. 2. Tell the client that his HCP will be notified if he continues to be verbally abusive -- this is communicating a threat (the HCP) 3. Call the HCP to obtain a prescription for a sedative - is not the initial action to take, but if abuse escalates is a second option.

What is the effect of beta-blocking agents when used for the treatment of glaucoma?

**When beta blockers are used to treat glaucoma, they are used to inhibit production of aqueous humor. -- rationales for incorrect answers: (a) enhance aqueous humor outflow = this is the action of miotic [or cholinergic] drugs to treat glaucoma: such as pilocarpine, which decrease eye pressure by increasing drainage of aqueous humor... rarely used today (2019). (b)

A middle-aged client asks the nurse what findings from his digital rectal exam -DRE- prompted the healthcare provider to prescribe a repeat serum prostatic surface antigen - PSA - level. What information should the nurse provide?

*PSA levels are prescribed to screen for prostate cancer which is often detected by the DRE and is manifested as small, hard, or stony, irregularly shaped nodules on the surface of the prostate. -- Although PSA levels are prescribed as routine screening, the findings suggestive of BPH: normal spongy or elastic texture, or infection that manifests by indentation of the prostate when HCP presses a finger into it, do not suggest prostate cancer, which would merit further testing.

During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him.. he continues "I look around to see who's talking to me, and I can't see anybody"... another client replies "I used to hear voices, too. I found out they were my imagination... the voices you hear aren't real either"... which phenomenon, common to groups, is exemplified in this interchange?

*Reality testing. -- a process in which an individual validates one's perception of reality. -- Group members can provide reality testing by monitoring each group member's reactions and behaviors, and by providing nonjudgemental feedback. --rationales for incorrect answer choices: (a) catharsis - In group therapy, catharsis is the release of intense, overwhelming emotions that members learn to express, and experience immediate relief. (b) universality - Group members experience universality when though awareness that they are not alone/unique and that others have reactions and thoughts similar to their own. (c) ventilation - verbalization of impulsive or negative feelings that reduces the risk of acting out the impulses/behaviors.

Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care? 1. If I fail another class, I am going to kill myself. 2. I have a necktie in my room that I can use to hang myself. 3. When I leave home to live on my own, I am buying myself a gun 4. I took two bottles of my mother's pills and had to have my stomach pumped.

2. I have a necktie in my room that I can use to hang myself. -- This answer choice suggest client has made a plan to harm himself. *Assessment of suicide ideation should include the degree of lethality of the method, the individual's access to whatever is needed to carry out the action, and the specifics of the plan. The more detailed that plan, the greater the risk.

A client with coronary artery disease (CAD) receives a prescription for clopidogrel / Plavix 300 mg PO. The medication is available in 75 mg tablets. How many tablets should the nurse administer?

300/75 = 4 tablets

Following the administration of sublingual nitroglycerin to a client experiencing an acute anginal attack, which assessment finding indicates to the nurse that the desired effect has been achieved? A) Client states chest pain is relieved. B) Client's pulse decreases from 120 to 90. C) Client's systolic blood pressure decreases from 180 to 90. D) Client's SaO2 level increases from 92% to 96%.

A) Client states chest pain is relieved. Nitroglycerin reduces myocardial oxygen consumption which decreases ischemia and reduces chest pain (A). (B and D) would also occur if the angina was relieved, but are not as significant as the client's subjective report of decreased pain. (C) may indicate a reduction in pain, or a potentially serious side effect of the medication.

A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement? A) Encourage the client to actively participate in assigned activities on the unit. B) Place a lock on the client's closet. C) Ignore the client's paranoid ideation to extinguish these behaviors. D) Explain to the client that his suspicions are false.

A) Encourage the client to actively participate in assigned activities on the unit. Diverting the client's attention from paranoid ideation and encouraging him to complete assignments can be helpful in assisting him to develop a positive self-image (A). The client's problem is not security, and (B) actually supports his paranoid ideation. (C) is not correct because ignoring the client's symptoms may lower his self-esteem. The nurse should not argue with the client about his delusions (D), and should not try to reason with the client regarding his paranoid ideation.

A client with hyperlipidemia receives a prescription for niacin (Niaspan). Which client teaching is most important for the nurse to provide? A) Expected duration of flushing. B) Symptoms of hyperglycemia. C) Diets that minimize GI irritation. D) Comfort measures for pruritis.

A) Expected duration of flushing. Flushing of the face and neck, lasting up to an hour, is a frequent reason for discontinuing niacin. Inclusion of this effect in client teaching (A) may promote compliance in taking the medication. While (B, C, and D) are all worthwhile instructions to help clients minimize or cope with normal side effects associated with niacin (Niaspan), flushing is intense and causes the most concern for the client.

A client is receiving digoxin for the onset of supraventricular tachycardia (SVT). Which laboratory findings should the nurse identify that places this client at risk? A) Hypokalemia. B) Hyponatremia. C) Hypercalcemia. D) Low uric acid levels.

A) Hypokalemia. Hypokalemia affects myocardial contractility, so (A) places this client at greatest risk for dysrhythmias that may be unresponsive to drug therapy. Although an imbalance of serum electrolytes, (B and C), can effect cardiac rhythm, the greatest risk for the client receiving digoxin is (A). (D) does not cause any interactions related to digoxin therapy for supraventricular tachycardia (SVT).

A client is admitted to the coronary care unit with a medical diagnosis of acute myocardial infarction. Which medication prescription decreases both preload and afterload? A) Nitroglycerin. B) Propranolol (Inderal). C) Morphine. D) Captopril (Capoten).

A) Nitroglycerin. Nitroglycerin (A) is a nitrate that causes peripheral vasodilation and decreases contractility, thereby decreasing both preload and afterload. (B) is a beta adrenergic blocker that decreases both heart rate and contractility, but only decreases afterload. Morphine (C) decreases myocardial oxygen consumption and preload. Capoten (D) is an angiotensin converting enzyme (ACE) inhibitor that acts to prevents vasoconstriction, thereby decreasing blood pressure and afterload.

Which method of medication administration provides the client with the greatest first-pass effect? A) Oral. B) Sublingual. C) Intravenous. D) Subcutaneous.

A) Oral. The first-pass effect is a pharmacokinetic phenomenon that is related to the drug's metabolism in the liver. After oral (A) medications are absorbed from the gastrointestinal tract, the drug is carried directly to the liver via the hepatic portal circulation where hepatic inactivation occurs and reduces the bioavailability of the drug. Alternative method of administration, such as sublingual (B), IV (C), and subcutaneous (D) routes, avoid this first-pass effect. The nitrate isosorbide dinitrate (Isordil) is prescribed for a client with angina. Which instruction should the nurse include in this client's discharge teaching plan? A) Quit taking the medication if dizziness occurs. B) Do not get up quickly. Always rise slowly. C) Take the medication with food only. D) Increase your intake of potassium-rich foods. B) Do not get up quick

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia?A) Propanolol (Inderal).B) Captopril (Capoten).C) Furosemide (Lasix).D) Dobutamine (Dobutrex).

A) Propanolol (Inderal).

A client is receiving methylprednisolone (Solu-Medrol) 40 mg IV daily. The nurse anticipates an increase in which laboratory value as the result of this medication? A) Serum glucose. B) Serum calcium. C) Red blood cells. D) Serum potassium.

A) Serum glucose. Solu-Medrol is a corticosteroid with glucocorticoid and mineralocorticoid actions. These effects can lead to hyperglycemia (A), which is reflected as an increase in the serum glucose value. The client taking Solu-Medrol is at risk for hypocalcemia (B) and hypokalemia (D), which result in a decrease, not an increase, in the serum calcium and serum potassium levels. This medication does not adversely affect the RBC count (C

The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? A) Withhold the scheduled dose. B) Check the client's apical pulse. C) Notify the healthcare provider. D) Repeat the serum potassium level.

A) Withhold the scheduled dose. The nurse should first withhold the scheduled dose of Cozaar (A) because the client is hyperkalemic (normal range 3.5 to 5 mEq/L). Although hypokalemia is usually associated with diuretic therapy in heart failure, hyperkalemia is associated with several heart failure medications, including ARBs. Because hyperkalemia may lead to cardiac dysrhythmias, the nurse should check the apical pulse for rate and rhythm (B), and the blood pressure. Before repeating the serum study (D), the nurse should notify the healthcare provider (C) of the findings.

A client with a dysrhythmia is to receive procainamide (Pronestyl) in 4 divided doses over the next 24 hours. What dosing schedule is best for the nurse to implement? A) q6h. B) QID. C) AC and bedtime. D) PC and bedtime.

A) q6h. Pronestyl is a class 1A antidysrhythmic. It should be taken around-the-clock (A) so that a stable blood level of the drug can be maintained, thereby decreasing the possibility of hypotension (an adverse effect) occurring because of too much of the drug circulating systemically at any particular time of day. (B, C, and D) do not provide an around-the-clock dosing schedule. Pronestyl may be given with food if GI distress is a problem, but an around-the-clock schedule should still be maintained.

A male client is brought to the emergency department by a police officer, who reports that the "client was disturbing the peace" by running around naked in the street, and striking out at others, and smashing car windows. *Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? SELECT ALL that apply. a. threats to kill his friend b. disruptive behaviors in a community setting c. hears voices telling him to kill himself d. reports that he has not needed a bath in 4 months e. created extensive private property damage f. says he has not eaten in 3 days.

A, C, D, & F. -- Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. -- Police officers and health care providers may be designated by statute to authorize the detention of persons who are a danger to themselves and others OR who are unable to provide themselves with basic needs due to mental illness. **B and E are civil issues, not factors related to involuntary commitment.

At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first? A. Ask a group member to seek help. B. Obtain the client's blood pressure. C. Position in a recovery position. D. Assess the client's level of orientation.

A. Ask a group member to seek help. First, help should be obtained while the nurse remains with the client (A). Next, assessment of the client (B and D) should be completed. Lastly, the client should be positioned (C) to prevent aspiration while recovering.

The nurse should expect the healthcare provider to prescribed what treatment regimen for a client with peptic ulcer caused by Helicobacter pylori? (Select all that apply.) A. Clarithromycin (Biaxin) b. Sulfisoxazole (Gantrisin) c. Misoprostol (Cytotec) D. Omeprazole (Prilosec). E. Metronidazole (Flagyl) f. Sulcrulfate (Carafate)

A. Clarithromycin (Biaxin) D. Omeprazole (Prilosec) E. Metronidazole (Flagyl) Rationale: Recommended medical treatment for Helicobacter pylori includes the use of at lease 2 different antibiotics and a proton pump inhibitor to decrease the incidence of antibiotic resistance, so (A, D, and E) are consistent with this protocol.

A 51 year old truck driver who smokes two packs of cigarettes a day and is 30 lbs overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? A. Information about smoking cessation. B. Diet instructions for a low-residue diet. C. Instruction on a weight-loss program. D. The importance of increasing milk in the diet.

A. Information about smoking cessation.

A male client is brought to the emergency department as the result of a motorcycle accident. He was not wearing a helmet at the time of the accident, and states that he has no intention of ever wearing one. Within the framework of the Transtheoretical Model (TTM), which response should the nurse provide? A. Wearing a helmet or not is certainly an individual decision. B. You should seriously consider wearing a helmet. C. Riding a motorcycle with a helmet increases your safety. D. I really think you don't have the facts about helmet use

A. Wearing a helmet or not is certainly an individual decision. Within the framework of the TTM, the client's comment indicates that he is in the pre-contemplation stage where he is not even considering change. By responding with (A), the nurse allows the client to express feelings and diffuses the strength of the response. (B, C, and D) are likely to make the contemplator more hostile and resistant to change.

A client who takes a statin and gemifibrozil (lopid) for hyperlipidemia reports onset of muscle pain and weakness. What additional assessment is most important for the nurse to obtain? A: Serum liver enzymes B: T3 and T4 blood levels C: Bowel Funciton D: Peripheral sensation

A: Serum liver enzymes Concomminent use of statins and gemifibrozil can cause muscle weakness and wasting known as myopathy, which is reflected in serum liver function enzyme levels, such as elevated serum aspartate aminotransferase (AST or SGOT) that is also found in skeletal muscles. --- Thyroid hormone levels are not effected by combo statins and gemifibrozil. --Changes in bowel function are common with statins, but this is not as important as liver function enzyme levels. --Peripheral neuropathy is a rare side effect of statins.

When assessing an adolescent who recently overdosed on acetaminophen (Tylenol), it is most important for the nurse to assess for pain in which area of the body? A) Flank. B) Abdomen. C) Chest. D) Head. B) Abdomen.

Acetaminophen toxicity can result in liver damage; therefore, it is especially important for the nurse to assess for pain in the right upper quadrant of the abdomen (B), which might indicate liver damage. (A, C, and D) are not areas where pain would be anticipated.

The mother of a 12 year old girl tells the school nurse that her child refuses to go to school because of vague physical complaints that the HCP indicates have no physiological basis. What action should the nurse take first?

Ask the mother if the child's sleep patterns have changed. -- Changes in sleep patterns are a symptom related to depression. If indicated, the nurse would conduct a full self-harm assessment. Neurovegetative symptoms of depression take priority over stressors such as homework, home life, and interactions with peers and teachers.

The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart failure. Which intervention should the nurse implement prior to administering the digoxin?

Assess the serum potassium level. --Hypokalemia (decreased serum potassium) will precipitate digitalis toxicity in persons receiving digoxin (B).

Which medications should the nurse caution the client about taking while receiving an opioid analgesic? A) Antacids. B) Benzodiazepines. C) Antihypertensives. D) Oral antidiabetics.

B) Benzodiazepines. Respiratory depression increases with the concurrent use of opioid analgesics and other central nervous system depressant agents, such as alcohol, barbiturates, and benzodiazepines (B). (A and D) do not interact with opiates to produce adverse effects. Antihypertensives (C) may cause morphine-induced hypotension, but should not be withheld without notifying the healthcare provider.

A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? A) Weight loss. B) Dizziness. C) Muscle cramps. D) Dry mucous membranes.

B) Dizziness. Angiotensin-converting enzyme (ACE) inhibitors are used in CHF to reduce afterload by reversing vasoconstriction common in heart failure. This vasodilation can cause hypotension and resultant dizziness (B). (A) is desired if fluid overload is present, and may occur as the result of effective combination drug therapy such as diuretics with ACE inhibitors. (C) often indicates hypokalemia in the client receiving diuretics. Excessive diuretic administration may result in fluid volume deficit, manifested by symptoms such as (D).

A client with heart failure is prescribed spironolactone (Aldactone). Which information is most important for the nurse to provide to the client about diet modifications? A) Do not add salt to foods during preparation. B) Refrain for eating foods high in potassium. C) Restrict fluid intake to 1000 ml per day. D) Increase intake of milk and milk products.

B) Refrain for eating foods high in potassium. Spironolactone (Aldactone), an aldosterone antagonist, is a potassium-sparing diuretic, so a diet high in potassium should be avoided (B), including potassium salt substitutes, which can lead to hyperkalemia. Although (A) is a common diet modification in heart failure, the risk of hyperkalemia is more important with Aldactone. Restriction of fluids (C) or increasing milk and milk products (D) are not indicated with this prescription.

A 43-year-old female client is receiving thyroid replacement hormone following a thyroidectomy. What adverse effects associated with thyroid hormone toxicity should the nurse instruct the client to report promptly to the healthcare provider? A) Tinnitus and dizziness. B) Tachycardia and chest pain. C) Dry skin and intolerance to cold. D) Weight gain and increased appetite.

B) Tachycardia and chest pain. Thyroid replacement hormone increases the metabolic rate of all tissues, so common signs and symptoms of toxicity include tachycardia and chest pain (B). (A, C, and D) do not indicate a thyroid hormone toxicity.

Which symptoms are serious adverse effects of beta-adrenergic blockers such as propranolol (Inderal)? A) Headache, hypertension, and blurred vision. B) Wheezing, hypotension, and AV block. C) Vomiting, dilated pupils, and papilledema. D) Tinnitus, muscle weakness, and tachypnea.

B) Wheezing, hypotension, and AV block. (B) represents the most serious adverse effects of beta-blocking agents. AV block is generally associated with bradycardia and results in potentially life-threatening decreases in cardiac output. Additionally, wheezing secondary to bronchospasm and hypotension represent life-threatening respiratory and cardiac disorders. (A, C, and D) are not associated with beta-blockers.

The healthcare provider prescribes naloxone (Narcan) for a client in the emergency room. Which assessment data would indicate that the naloxone has been effective? The client's A) statement that the chest pain is better. B) respiratory rate is 16 breaths/minute. C) seizure activity has stopped temporarily. D) pupils are constricted bilaterally.

B) respiratory rate is 16 breaths/minute. Naloxone (Narcan) is a narcotic antagonist that reverses the respiratory depression effects of opiate overdose, so assessment of a normal respiratory rate (B) would indicate that the respiratory depression has been halted. (A, C, and D) are not related to naloxone (Narcan) administration.

A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for an involuntary commitment? (Choose all that apply.) A. Created extensive private property damage. B. Threatens to kill his friend. C. Says he has not eaten in 3 days. Correct D. Reports he has not needed a bath in 4 months. E. Disruptive behaviors in a community setting. F. Hears voices telling him to kill himself.

B, C, D, F -- Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others or who are unable to provide for their own basic needs due to mental illness. (A and E) are civil issues, not factors related to involuntary commitment.

The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? A. Flush the tube with 50 ml of water q 8 hours. B. Check for tube placement and residual volume q4 hours. C. Obtain a daily x-ray to verify tube placement. D. Position on left side with head of bed elevated 45 degrees

B. Check for tube placement and residual volume q4 hours. --Tube placement and residual volume should be checked before each feeding. Placement is checked by aspiration of stomach contents and measurement of pH.

Which milestone indicates to the nurse successful achievement of young adulthood? A. Demonstrates a conceptualization of death and dying. B. Completes education and becomes self-supporting. C. Creates a new definition of self and roles with others .D. Develops a strong need for parental support and approval.

B. Completes education and becomes self-supporting. (A and C) - adolescence (D) - indicates dependency, which is a developmental delay.

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?A. Serum PTT of 10 seconds. B. Serum calcium of 5 mg/dl. C. Oxygen saturation of 90%. D. Hemoglobin of 10 g/dl.

B. Serum calcium of 5 mg/dl. --TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia.

The nurse is caring for a client after a transurethral resection of the prostate and determines the client's urinary catheter is not draining. What should the nurse implement? A. encourage the client to drink oral fluids B. change drainage unit tubing C. irrigate the catheter D. reposition the catheter drainage tubing

C Obstruction urinary flow after a TURP is most often due to blood clot, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.

A client's dose of isosorbide dinitrate (Imdur) is increased from 40 mg to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled dose, which action should the nurse implement? A) Hold the next scheduled dose of Imdur 60 mg and administer a PRN dose of acetaminophen (Tylenol). B) Administer the 40 mg of Imdur and then contact the healthcare provider. C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). D) Do not administer the next dose of Imdur or any acetaminophen until notifying the healthcare provider.

C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). Imdur is a nitrate which causes vasodilation. This vasodilation can result in headaches, which can generally be controlled with acetaminophen (C) until the client develops a tolerance to this adverse effect. (A and B) may result in the onset of angina if a therapeutic level of Imdur is not maintained. Lying down (D) is less likely to reduce the headache than is a mild analgesic.

Which action is most important for the nurse to implement prior to the administration of the antiarrhythmic drug adenosine (Adenocard)? A) Assess pupillary response to light. B) Instruct the client that facial flushing may occur. C) Apply continuous cardiac monitoring. D) Request that family members leave the room.

C) Apply continuous cardiac monitoring. Adenosine (Adenocard) is an antiarrhythmic drug used to restore a normal sinus rhythm in clients with rapid supraventricular tachycardia. The client's heart rate should be monitored continuously (C) for the onset of additional arrhythmias while receiving adenosine. (A and B) are valuable nursing interventions, but are of less importance than monitoring for potentially fatal arrhythmias. Family members may be asked to leave the room because of the potential for an emergency situation (D), however, this is also of less priority than (C).

The nurse is assessing a client who is experiencing anaphylaxis from an insect sting. Which prescription should the nurse prepare to administer this client? A) Dopamine. B) Ephedrine. C) Epinephrine. D) Diphenhydramine.

C) Epinephrine. Epinephrine (C) is an adrenergic agent that stimulate beta receptors to increase cardiac automaticity in cardiac arrest and relax bronchospasms in anaphylaxis. Dopamine (A) is a vasopressor used to treat clients with shock. Ephedrine (B) causes peripheral vasoconstriction and is used in the treatment of nasal congestion. Diphenhydramine (D) is an antihistamine decongestant used in the treatment of mild allergic reactions and motion sickness.

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care? A) Have you ever experienced any paralysis of your arms or legs? B) Have you ever sustained a severe head injury? C) Have you ever been 'frozen' in one spot, unable to move? D) Do you have headaches, especially ones with throbbing pain?

C) Have you ever been 'frozen' in one spot, unable to move?

A client who was prescribed atorvastatin (Lipitor) one month ago calls the triage nurse at the clinic complaining of muscle pain and weakness in his legs. Which statement reflects the correct drug-specific teaching the nurse should provide to this client? A) Increase consumption of potassium-rich foods since low potassium levels can cause muscle spasms. B) Have serum electrolytes checked at the next scheduled appointment to assess hyponatremia, a cause of cramping. C) Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect. D) Be sure to consume a low-cholesterol diet while taking the drug to enhance the effectiveness of the drug.

C) Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect. Myopathy, suggested by the leg pain and weakness, is a serious, and potentially life-threatening, complication of Lipitor, and should be evaluated immediately by the healthcare provider (C). Although electrolyte imbalances such as (A or B) can cause muscle spasms in some cases, this is not the likely cause of leg pain in the client receiving Lipitor, and evaluation by the healthcare provider should not be delayed for any reason. A low-cholesterol diet is recommended for those taking Lipitor since the drug is used to lower total cholesterol (D), but diet is not related to the leg pain symptom.

Which nursing diagnosis is important to include in the plan of care for a client receiving the angiotensin-2 receptor antagonist irbesartan (Avapro)? A) Fluid volume deficit. B) Risk for infection. C) Risk for injury. D) Impaired sleep patterns.

C) Risk for injury. Avapro is an antihypertensive agent, which acts by blocking vasoconstrictor effects at various receptor sites. This can cause hypotension and dizziness, placing the client at high risk for injury (C). Avapro does not act as a diuretic (A), impact the immune system (B), or alter sleep patterns (D).

A 6-year-old child is admitted in the emergency department with a systolic blood pressure of 58 mm Hg. What action should the nurse take first? A) comfort the child B) assess responsiveness C) alert the healthcare provider D) initiate Iv fluid replacement

C) alert the healthcare provider WHY? The lower limit for systolic blood pressure for a child older than 1 year of age is 70 mm Hg plus 2 times the child's age in years, so the healthcare provider should be notified (C) of the child's hypotension, and although comforting measures should be provided (A), physiological needs should be met first. Assessing the child's responsiveness is a component of a neurologic assessment, but asystolic blood pressure of 58 mm Hg is a late sign of shock in children and requires immediate intervention (B). The healthcare provider's prescriptions, including IV fluids (D), should be obtained to address shock.

What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina? A. Instruct the client to look at examiner's nose and not move his/her eyes during the exam. B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. D. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? A. Increased WBC, decreased RBC. B. Increased serum bilirubin, slightly increased liver enzymes. C. Increased protein in the urine, slightly increased serum glucose levels. D. Decreased serum sodium, an increased urine specific gravity.

C. Increased protein in the urine, slightly increased serum glucose levels. --In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical UTIs.

The nurse is working with a 71 year old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? A. Increase the amount of calcium intake in the diet. B. Apply alternating heat and cold therapies. C. Initiate a weight-reduction diet to achieve a healthy body weight. D. Use a walker for ambulation to lessen weight-bearing on the hips.

C. Initiate a weight-reduction diet to achieve a healthy body weight.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope?

C. May indicate pneumonia.The test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as muffled or unclear. Increased clarity of a spoken word is indicative of some sort of consolidation process (tumor, pneumonia) and is not a normal finding.

A 67 year old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? A. Failing eyesight resulting in an unsafe environment. B. Renal osteodystrophy resulting from chronic renal failure. C. Osteoporosis resulting from hormonal changes. D. Cardiovascular changes resulting in small strokes which impair mental acuity.

C. Osteoporosis resulting from hormonal changes.

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and type of receptors found on the cancer cells. Which explanation should the nurse provide? A. Lymph node involvement is not significant. B. Small tumors are aggressive and indicate poor prognosis. C. The tumor's estrogen receptor guides treatment options. D. Stage I indicates metastasis.

C. The tumor's estrogen receptor guides treatment options.

What discharge instruction is most important for a client after a kidney transplant? A. Weigh weekly. B. Report symptoms of secondary Candidiasis. C. Use daily reminders to take immunosuppressants. D. Stop cigarette smoking.

C. Use daily reminders to take immunosuppressants. --Acute rejection is a risk for several months, so immunosuppressive therapy such as corticosteroids and azathioprine (Imuran) is essential in preventing rejection.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Present knowledge related to the skill of injection. B. Intelligence and developmental level of the client. C. Willingness of the client to learn the injection sites. D. Financial resources available for the equipment.

C. Willingness of the client to learn the injection sites.

What intervention should the nurse include in the care plan for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Check capillary refill of toes on lower extremity with Unna's paste boot Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation. Kerlix is often wrapped around the outside of the boot and an ACE bandage may be used to cover both, but No bandage should be put under it. -- The Unna's paste boot should be applied from foot & wrapped towards knee. It acts as a sterile dressing & should not be removed q8h. Weekly removal is reasonable.

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? a. Listen to bilateral lung and bowel sounds. b. Obtain the client's pulse and blood pressure. c. Assist the client to the bathroom to void. d. Check the client's gag and swallow reflexes.

Check the client's gag and swallow reflexes. Following gastroscopy, a client should remain nothing by mouth until the effects of local anesthesia have dissipated and the airway's protective reflexes, gag and swallow reflexes, have returned (D). (A, B, and C) are not the priority before reintroducing oral fluids after a gastroscopy.

A client is receiving clonidine (Catapres) 0.1 mg/24hr via transdermal patch. Which assessment finding indicates that the desired effect of the medication has been achieved? A) Client denies recent episodes of angina. B) Change in peripheral edema from +3 to +1. C) Client denies recent nausea or vomiting. D) Blood pressure has changed from 180/120 to 140/70.

D) Blood pressure has changed from 180/120 to 140/70. Catapres acts as a centrally-acting analgesic and antihypertensive agent. (D) indicates a reduction in hypertension. Catapres does not affect (A, B, or C), so these findings do not indicate desired outcomes of Catapres.

Which change in data indicates to the nurse that the desired effect of the angiotensin II receptor antagonist valsartan (Diovan) has been achieved? A) Dependent edema reduced from +3 to +1. B) Serum HDL increased from 35 to 55 mg/dl. C) Pulse rate reduced from 150 to 90 beats/minute. D) Blood pressure reduced from 160/90 to 130/80.

D) Blood pressure reduced from 160/90 to 130/80. Diovan is an angiotensin receptor blocker, prescribed for the treatment of hypertension. The desired effect is a decrease in blood pressure (D). (A, B, and C) do not describe effects of Diovan.

An older client with a decreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process? A) Absorption. B) Metabolism. C) Elimination. D) Distribution.

D) Distribution. A decreased lean body mass in an older adult affects the distribution of drugs (D), which affects the pharmacokinetics of drugs. Decreased gastric pH, delayed gastric emptying, decreased splanchnic blood flow, decreased gastrointestinal absorption surface areas and motility affect (A) in the older adult population. Decreased hepatic blood flow, decreased hepatic mass, and decreased activity of hepatic enzymes affect (B) in older adults. Decreased renal blood flow, decreased glomerular filtration rate, decreased tubular secretion, and decreased number of nephrons affects (C) in an older adult.

Dobutamine (Dobutrex) is an emergency drug most commonly prescribed for a client with which condition? A) Shock. B) Asthma. C) Hypotension. D) Heart failure.

D) Heart failure. Dobutamine is a beta-1 adrenergic agonist that is indicated for short term use in cardiac decompensation or heart failure (D) related to reduced cardiac contractility due to organic heart disease or cardiac surgical procedures. Alpha and beta adrenergic agonists, such as epinephrine and dopamine, are sympathomimetics used in the treatment of shock (A). Other selective beta-2 adrenergic agonists, such as terbutaline and isoproterenol, are indicated in the treatment of asthma (B). Although dobutamine improves cardiac output, it is not used to treat hypotension (C).

A client has a continuous IV infusion of dopamine (Intropin) and an IV of normal saline at 50 ml/hour. The nurse notes that the client's urinary output has been 20 ml/hour for the last two hours. Which intervention should the nurse initiate? A) Stop the infusion of dopamine. B) Change the normal saline to a keep open rate. C) Replace the urinary catheter. D) Notify the healthcare provider of the urinary output.

D) Notify the healthcare provider of the urinary output. The main effect of dopamine is adrenergic stimulation used to increase cardiac output, which should also result in increased urinary output. A urinary output of less than 20 ml/hour is oliguria and should be reported to the healthcare provider (D) so that the dose of dopamine can be adjusted. Depending on the current rate of administration, the dose may need to be increased or decreased. If the dose is decreased, it should be titrated down, rather than abruptly discontinued (A). Fluid intake may need to be increased, rather than (B). The urinary catheter is draining and does not need to be replaced (C).

A client with coronary artery disease who is taking digoxin (Lanoxin) receives a new prescription for atorvastatin (Lipitor). Two weeks after initiation of the Lipitor prescription, the nurse assesses the client. Which finding requires the most immediate intervention? A) Heartburn. B) Headache. C) Constipation. D) Vomiting.

D) Vomiting. Vomiting, anorexia and abdominal pain are early indications of digitalis toxicity. Since Lipitor increases the risk for digitalis toxicity, this finding requires the most immediate intervention.

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?

D. Bronchodilators and steroids.

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? A. An increase in abdominal girth. B. Hypertension and a bounding pulse. C. Decreased bowel sounds. D. Difficulty in handwriting.

D. Difficulty in handwriting. (A) is a sign of ascites. (B) are not seen with hepatic encephalopathy. (C) does not indicate an increase in serum ammonia level, which is primary cause of hepatic encephalopathy.

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client? A. Xylocaine (Lidocaine). B. Procainamide (Pronestyl). C. Phenytoin (Dilantin). D. Digoxin (Lanoxin).

D. Digoxin (Lanoxin).

During a health fair, a 72 year old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have?

D. Productive cough with grayish-white sputum.

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement?

D. Question the HCP's prescription. Magnesium agents are not usually used for clients with CKD due to risk of hypermagnesemia.

A client with GERD has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A. Losing weight. B. Decreasing caffeine intake. C. Avoiding large meals. D. Raising the head of the bed on blocks.

D. Raising the head of the bed on blocks.

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client? a. Xylocaine (Lidocaine). b. Procainamide (Pronestyl). c. Phenytoin (Dilantin). d. Digoxin (Lanoxin).

Digoxin (Lanoxin). Digoxin (Lanoxin) (D) is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and effecting cardiac output. (A, B, and C) are not indicated in the initial treatment of uncontrolled atrial fibrillation.

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care? a. Have you ever experienced any paralysis of your arms or legs? b. Have you ever sustained a severe head injury? c. Have you ever been 'frozen' in one spot, unable to move? d. Do you have headaches, especially ones with throbbing pain?

Have you ever been 'frozen' in one spot, unable to move? Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not cause (A). Parkinson's disease is not usually associated with (B), nor does it typically cause (D).

A medication that is classified as a beta-1 agonist is most commonly prescribed for a client with which condition? A. Glaucoma B. Hypertension C. Heart Failure D. Asthma

Heart failure -- Beta 1 agonists improve cardiac output by increasing heart rate and blood pressure and are indicated for heart failure, shock, atrioventricular block dysrhythmias, and cardiac arrest. Beta 1 "blockers" are used in the management of hypertension. Combination therapy is used to treat glaucoma: using adrenergic agents and beta-adrenergic blocking agents. For asthma, medications that stimulate beta-2 receptors of the lungs are effective for bronchoconstrictive respiratory disorders.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? a. Give 20 mEq of potassium chloride. b. Initiate continuous cardiac monitoring. c. Arrange a consultation with the dietician. d. Teach about the side effects of diuretics.

Initiate continuous cardiac monitoring.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?

Instruct the client that the stoma will become smaller when the initial swelling diminishes. --- Postoperative swelling causes enlargement of the stoma.

When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness?

Interpersonal and intrapersonal skills. -- These skills form one's personal intelligence, or "emotional quotient, " so the nurse should focus inquiries on social skills. -- Other answers: Linguistic and musical abilities, and logical mathematics skills evaluate a client's cognitive and mental status. Bodily kinesthetic and spatial abilities determine neurophysical interpretation of one's body in the environment.

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?

My mouth feels like cotton A dry mouth (A) is an anticholinergic effect that is an expected side effect of MAO inhibitors such as phenelzine sulfate (Nardil). (B, C, and D) are not expected side effects of this medication.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

Others have had similar thoughts when under stress --- This response offers support by assuring the client that others have suffered as he has (also the principle by which Alcoholics Anonymous acts).

A client receives a new prescription for nitroglycerin / Nitrostat tablets. Which instruction should the nurse include in this client's teaching?

Place under the tongue as needed every 5 minutes up to three times -- call 911 of pain persists. Nitroglycerin tablets are taken sublingually (SL) to avoid first pass effect. It should be taken at the onset of chest pain to expedite oxygen flow to the myocardial tissues. Nitroglycerin is a vasodilator, so the client should be instructed to rest and to change positions from lying to sitting to standing cautiously to avoid orthostatic hypertension.

The nurse is assessing a client with chronic renal failure (CRF). Which finding is most important for the nurse to respond to first? a. Potassium 6.0 mEq. b. Daily urine output of 400 ml. c. Peripheral neuropathy. d. Uremic fetor.

Potassium 6.0 mEq. Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so (A) is the nursing priority. (B) is an expected finding associated with renal tubular destruction. In CRF, an increase in serum nitrogenous waste products, electrolyte imbalances, and demyelination of the nerve fibers contribute to the development of (C). (D) is a urinous odor of the breath related to the accumulation of blood urea nitrogen and is a common complication of CRF, but not as significant as hyperkalemia.

A 9-month-old infant receives a prescription for digoxin 40 mcg PO daily. Digoxin Oral Solution, USP 50 mcg (0.05 mg) per ml is available. How many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

Rationale Using ratio and proportion, 40 mcg : X ml :: 50 mcg : 1 ml = 0.8 ml

A client is scheduled to complete a positron emission tomography (PET) scan.The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?

Results show activity in various portions of the brain: the results of a PET scan (used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease) shows brightly colored cerebral areas where an accumulation of radioactively tagged glucose is used as a tracer to visualize brain activity, blood flow, and glucose metabolism.

An emergency department triage nurse is interviewing a female client with a history of epilepsy with tonic clonic seizures controlled by Dilantin / phenytoin. Which information is most significant in planning this client's care?

She ran out of her medication 4 days ago. -- Abruptly stopping anticonvulsant medication can induce a seizure or the development of status epilepticus. Immediate seizure precautions and administration of medications are needed.

A 19 year old female client with anorexia nervosa wants to help serve dinner trays to other clients on the psychiatric unit. What action should the nurse take?

Suggest another way for this client to participate in the unit's activities. -- Clients with anorexia nervosa should not be allowed to prepare or serve food for unit activities and their desire to do should be redirected. These clients find pleasure in providing others food and watching them eat which reinforces their perception of self-control.

Which client should the nurse identify as being at highest risk for complications during the use of an opioid analgesic? A) An older client with Type 2 diabetes mellitus. B) A client with chronic rheumatoid arthritis. C) A client with an open compound fracture. D) A young adult with inflammatory bowel disease. D) A young adult with inflammatory bowel disease.

The principal indication for opioid use is acute pain, and a client with inflammatory bowel disease (D) is at risk for toxic megacolon or paralytic ileus related to slowed peristalsis, a side effect of morphine. Adverse effects of morphine do not pose as great a risk for (A, B, and C) as the client with bowel disease.

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? a. I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight. b. I will let you have one cracker, but that is all you can have for the rest of tonight. c. What did the healthcare provider tell you about the test you are having tomorrow? d. The test you are having tomorrow requires that you have nothing by mouth tonight.

The test you are having tomorrow requires that you have nothing by mouth tonight. (D) is the most therapeutic statement because the nurse is responding to the client's question. (A) is not an explanation and the nurse should teach the client why eating is prohibited after midnight, rather than enforcing this requirement without an explanation for it. (B) may result in an inaccurate test result, or may cause the test to be cancelled, which could also delay diagnosis and treatment. (C) defers the responsibility for answering the client's question to the healthcare provider, when the nurse could address the situation through client teaching.

The nurse is transcribing a new prescription for spironolactone (Aldactone) for a client who receives an angiotensin-converting enzyme (ACE) inhibitor. Which action should the nurse implement?

Verify both prescriptions with the healthcare provider. --- The concomitant use of an angiotensin-converting enzyme (ACE) inhibitor and a potassium-sparing diuretic such as spironolactone, should be given with caution because the two drugs may interact to cause an elevation in serum potassium levels. Although the client is currently receiving an ACE inhibitor, verifying both prescriptions (A) alerts the healthcare provider about the client's medication regimen and provides the safest action before administering the medication.

The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, " The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?

What do you believe the news commentator said to you? -- It is imperative that the nurse determine what the client believes she heard. The idea of reference may be to harm herself or someone else. The main function of the psychiatric nurse is to maintain safety.

A nurse should withhold which medication if the client reports nausea, vomiting, and diarrhea? a. colchicine / Colchicine b. erythromycin / E-Mycin c. naproxen / Aleve, Naprosyn d. labetolol / Normodyne

a. colchicine / Colchicine -- used to prevent or treat attacks of gout (also called gouty arthritis) by decreasing swelling and lessening the build-up of uric acid crystals that cause pain in the affected joint(s). -- Symptoms of overdose/toxicity include nausea, vomiting, and diarrhea, and can be life-threatening. --- These symptoms may occur with the other answer choices but are not life threatening so those medications do not need to be withheld.

The nurse is planning the care for a 32 year old male client with acute depression. Which nursing intervention would be best in helping this client with his depression? a. ensure that the client's day is full of group activities b. assist the client in exploring feelings of shame, anger, and guilt c. allow the client to initiate and determining ADLs d. encourage the client to explore the rationale for his depression

b. assist the client in exploring feelings of shame, anger, and guilt. -- Depression is associated with feelings of shame, anger, and guilt. Exploring these feelings is therapeutic for a client experiencing depression. --- The other answer choices do not allow for this exploration. Answer "c" is correct for a client with chronic depression who is exhibiting vegetative signs of depression. Answer "d" is equivalent to asking the client a "why" question.

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that the client understands this dietary restriction? a. tossed salad, low-sodium salad dressing, bacon and tomato sandwich b. New England clam chowder, no-salt crackers, fresh fruit salad c. skim milk, turkey salad, roll, vanilla ice cream d. macaroni and cheese, diet coke, slice of cherry pie

c. skim milk, turkey salad, roll, vanilla ice cream. -- while containing some sodium are considered low sodium foods. --- Bacon, canned soups, especially ones containing seafood, hard cheeses, macaroni, and most diet drinks are VERY high in sodium.

A patient who has undergone endoscopy / gastroscopy is fully awake and asks the nurse for something to drink. After confirming that liquids are allowed on the primary care provider order sheet, the nurse should: a. assist the patient to the bathroom to void. b. listen to lung sounds. c. take a blood pressure and pulse. d. check for the return of gag and swallow reflexes.

d. check for the return of gag and swallow reflexes. Following a gastroscopy/endoscopy, a client should remain NPO - nothing by mouth - until the effects of the anesthesia have dissipated and the airway's protective reflexes, gag and swallow reflexes, have returned.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to help this client? a. losing weight b. decreasing caffeine intake c. avoiding large meals d. raising the head of bed on blocks.

d. raising the head of bed on blocks. -- This is also known as reverse trendelenbug position and is the MOST effective of the answer choices to reduce reflux and potential aspiration. **The other answer choices are helpful but not MOST effective.

A client with hypertension receives a prescription for carteolol / Cartel 7.5 mg PO daily. The drug is available in 2.5 mg tablets. How many tablets should the nurse administer?

desired dose divide by available then multiply result times number of unit. -- 7.5 mg / 2.5 mg ... the mg cancel out leaving numberical solution to multipy times 1 tablet. -- Solution = 3 tablets

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly ____

often follows relocation to new surroundings. -- Moving is stressful for one of any age. Stress in the elderly often manifests as confusion. -- Adequate sleep can not prevent stress.

The nurse would be correct in holding a dose of digoxin in a client with CHF without specific instruction from HCP if the client's A) serum digoxin level is 1.5 B) blood pressure is 104/68 C) serum potassium level is 3 D) apical pulse is 68/min

serum potassium level is 3

The nurse would be correct for withholding a dose of digoxin in a client with congestive heart failure (CHF) without specific instruction from the healthcare provider (HCP) if the client's _____

serum potassium level is 3 (norm is 3.5-5.5 mEq/L). -- rationales incorrect answer choices: serum digoxin 1.5 (therapeutic range: o.8-2 ng/ml; toxic levels above 2). A blood pressure 104/68 would not warrant withholding digoxin. An apical pulse of 68/minute is above the minimum threshold of 60/min -- withhold digoxin if apical pulse is below 60/min.

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? a. "Does the client have her own teeth or dentures?" b. take aspirin and if so, how much?" c. take nitroglycerin?" d. take digitalis?"

take digitalis?" Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. (A) is irrelevant.

A male client tells the nurse that the voices he hears are telling him to kill himself. To assist the client in coping with these thoughts the nurse should ____

tell the client to tell himself that these voices are unreasonable. -- This is an example of self talk technique. Clients with schizophrenia have difficulty interacting with others so instructing the client to tell someone about what he is hearing would not be effective. Auditory hallucinations are often relentless and not easily ignored so instructing the client to ignore the voices would not be effective.