Q Dynamic Quiz Fundamentals and Pharmacology

A nurse is caring for a child who has epilepsy and is scheduled to receive a dose of phenytoin. The nurse notes the child's serum phenytoin level is 14 mcg/mL. Which of the following actions should the nurse take? 1. Administer the dose 2. Administer half the dose 3. Do not administer the dose 4. Clarify the dose with the provider

1. Administer the dose A serum phenytoin level to 14 mcg/mL is within the expected reference range of 10 to 20 mcg/mL. The nurse should administer the medication as prescribed

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? 1. Sit besides the client during the interview 2. Make sure the device if functioning 3. Make sure lighting in the room is soft 4. Provide a lengthy interview process to allow adequate time to answer questions.

2. Make sure the device if functioning

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthetic care unit. Which of the following assessments should the nurse make first? 1. Pain level 2. Hydration status 3. Airway 4. Urinary output

3. Airway

A nurse is caring for a client who has a new prescription for amphotericin B. The nurse should plan to monitor the client for which of the following adverse effects? 1. Hyperkalemia 2. Hypertension 3. Constipation 4. Nephrotoxicity

4. Nephrotoxicity Amphotericin B is an antifungal medication used to treat severe fungal infections; however, it can cause nephrotoxicity. The nurse should monitor the client's creatinine every 3 to 4 days and increase fluid intake. The dosage of amphotericin B should be reduced if the client's creatinine is 3.5 mg/dL or greater. Amphotericin B can cause hypokalemia, hypotension, and diarrhea as adverse side effects.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? 1. Auscultate the blood pressure at the dorsalis pedis artery 2. Measure the blood pressure with the client sitting on the side of the bed 3. Place the cuff 7.6 cm (3 in) above the popliteal artery 4. Place the bladder of the cuff over the posterior aspect of the thigh.

4. Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the bladder of the cuff when the nurse is measuring a lower-extremity blood pressure. When taking the blood pressure on a lower extremity the nurse should auscultate the blood pressure at the popliteal artery. The nurse should measure the blood pressure with the client prone if possible. If not possible then the client should lie supine with the knee flexed. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.

A nurse is preparing to administer 100 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take? 1. Verify with the provider about giving insulin glargine at 1700 2. Ensure the insulin glargine is a cloudy suspension 3. Request a prescription for giving insulin glargine twice daily 4. Use separate syringes for administering insulin glargine and NPH insulin

4. Use separate syringes for administering insulin glargine and NPH insulin The nurse should not mix insulin glargine with any other insulin. The nurse should administer the NPH insulin and insulin glargine separately. The nurse may administer insulin glargine at any time of the day. Insulin glargine is a clear solution. The nurse should administer insulin glargine only once in a 24-hour period.

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

A nurse is teaching a client about a new prescription for extended-release oxycodone for pain management. Which of the following statements should the nurse include in the teaching? 1. "Swallow this medication whole." 2. "Take this medication before meals and at bedtime." 3. "Constipation decreases with continued use." 4. "Avoid taking other supplemental analgesics with this medication."

1. "Swallow this medication whole." The nurse should tell the client that extended-release oxycodone is a long-acting medication and should not be cut in half or crushed to prevent immediate absorption of the entire dose. This medication should be swallowed whole and is administered every 12 hours. The nurse should tell the client that extended-release oxycodone is a long-acting opioid and is usually prescribed once every 12 hours and not PRN. The client can take oxycodone with food or milk to decrease gastric irritation. The nurse should tell the client that extended-release oxycodone can cause chronic constipation. The nurse should teach the client to increase intake of fluids and fiber to prevent chronic constipation. The nurse should tell the client that when using extended-release oxycodone a supplement short-acting opioid medication can be taken for breakthrough pain.

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? 1. "Tell me what I can do to help you overcome your fear of giving yourself injections." 2. "Your provider will not be pleased that you refuse to give yourself insulin injections." 3. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." 4. "You won't be able to go home unless you learn to give yourself insulin injections."

1. "Tell me what I can do to help you overcome your fear of giving yourself injections." This response illustrates the therapeutic communication technique of clarifying and offering self. The nurse should allow the client to express feelings and fears and support the client in learning how to give the injections.

A charge nurse is teaching a newly licensed nurse about the purpose of a client being prescribed a transdermal fentanyl patch. Which of the following clients should the charge nurse include in the teaching as a client who requires this medication? 1. A client who is opioid-tolerant 2. A client who has difficulty swallowing 3. A client who has severe intermittent pain 4. A client who is postoperative following abdominal surgery

1. A client who is opioid-tolerant The charge nurse should include in the teaching that a client who is opioid tolerant can be prescribed a fentanyl patch to manage the pain. A client who has severe, persistent pain also should be eligible to be prescribed a transdermal fentanyl patch.

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider? 1. Aspirin EC 325 mg per NG tube daily 2. Atorvastatin 40 mg per NG tube daily 3. Propranolol 20 mg per NG tube daily 4. Sucralfate 2g Oral suspension per NG tube BID

1. Aspirin EC 325 mg per NG tube daily The nurse should clarify the prescription for aspirin EC 325 mg per NG tube daily, as enteric-coated tablets should not be crusted.

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? 1. Auscultation 2. Light palpation 3. Percussion 4. Deep palpation

1. Auscultation

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? 1. Elevating the finger above heart level 2. Rubbing the fingertip with an alcohol pad 3. Puncturing the side of the fingertip 4. Wrapping the finger in a warm cloth

1. Elevating the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart, in a dependent position; will help increase blood flow to the area and ensure an adequate specimen for collection. The client should clean the finger with an antiseptic swab or with soap and water. The client should allow the fingertip to dry completely The client should puncture the side of the finger, avoiding sites besides the bone. The client should wrap the finger in a war cloth to increase blood flow to the area.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? 1. Establish client outcomes. 2. Collect information about past health problems 3. Determine whether the client has met specific goals 4. Identify the client's specific health problems.

1. Establish client outcomes. The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care. The nurse should collect information about the client's past health problems during the assessment phase of the nursing process. The nurse should identify the client's specific health problems during the analysis phase of the nursing process

A nurse is caring for a client who has a new prescription for levothyroxine to treat hypothyroidism. which of the following findings should the nurse identify as an indication that the client requires intervention? 1. Heart rate of 106/min 2. Dry skin 3. Oral temperature 36.8 (98.2 F) 4. Lethargy

1. Heart rate of 106/min Tachycardia can be a manifestation of hyperthyroidism, possibly due to excessive hormone replacement. The client might require a lower dosage of levothyroxine. Dry skin is a common manifestation of hypothyroidism, which should resolve after medication therapy achieves euthyroidism Lethargy is a common manifestation of hypothyroidism.

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? 1. Hydrocolloid 2. Collagen 3. Calcium alginate 4. Proteolytic enzyme

1. Hydrocolloid The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin. Collagen should be applied to a clean, moist wound to stop bleeding, and to bring cells into the wound, and to stimulate their proliferation to facilitate healing. The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of dressing is used for wounds with significant exudate and must be covered with a secondary dressing. The nurse should apply proteolytic enzyme to an unstageable pressure ulcer. This type of dressing is applied to facilitate debridement and to soften eschar.

A nurse is preparing a continuous IV infusion of erythromycin lactobionate for a client who has a Bordetella pertussis infection. Which of the following actions should the nurse take to minimize the risk of thrombophlebitis? 1. Infuse the medication slowly 2. Administer half the dosage 3. Avoid diluting the solution 4. Initiate intermittent dosing

1. Infuse the medication slowly The nurse should infuse erythromycin slowly to minimize the risk of thrombophlebitis, which is an inflammatory process resulting from the formation of a blood clot in the vein. These blood clots usually form in the legs. Infusing erythromycin in a dilute solution is also an effective way to minimize the risk of thrombophlebitis, but this is not the answer they were looking for. A continuous infusion of erythromycin is preferable to intermittent dosing. Intermittent dosing will not minimize the risk of thrombophlebitis.

A nurse is caring for a client who developed hypoglycemia following an insulin injection. The client is conscious and responds appropriately to verbal stimuli. Which of the following medications should the nurse plan to administer first? 1. Oral glucose tablet 2. 50% dextrose intravenously 3. Glucagon intramuscularly 4. Epinephrine intravenously

1. Oral glucose tablet Evidence-based practice indicates that a client who has mild hypoglycemia and is conscious and able to swallow should receive an oral agent such as an oral glucose tablet. If the client is unresponsive to the oral glucose tablet, another, more invasive form of treatment can be initiated. The intravenous administration of 50% dextrose should be reserved for clients who have severe hypoglycemia and are unable to swallow. The intramuscular administration of glucagon should be reserved for clients who have severe hypoglycemia and are unable to swallow. The nurse should place the client in a lateral position because this form of glucagon can induce vomiting, and this position reduces the risk of aspiration. The intravenous administration of epinephrine should be reserved for clients who have severe hypoglycemia and are unconscious, and are unresponsive to other medications that treat hypoglycemia.

A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority? 1. Paresthesia 2. Alopecia 3. Stomatitis 4. Constipation

1. Paresthesia The greatest risk to this client is neurotoxicity. Vincristine, a cell-cycle specific chemotherapy agent, interrupts cellular reproduction at mitosis and can cause neurotoxicity. An early finding with neurotoxicity is paresthesia (numbing) of the peripheral extremities. As neurotoxicity progresses, the client can develop autonomic and central nervous system dysfunction. The nurse should report paresthesia immediately, as the provider might change the dosage or the therapy.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plant to take? 1. Place the client in the Trendelenburg position 2. Perform percussions directly over the client's bare skin 3. Use a flattened hand to perform percussions 4. Remind the client that chest percussions can cause mild pain.

1. Place the client in the Trendelenburg position The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's lower left lobe. The nurse should perform percussions over a single layer of clothing and the hand should be cupped. The chest percussions should not cause pain.

A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the following assessments is the nurse's priority? 1. Pulmonary function 2. CBC 3. Urinary output 4. Peripheral edema

1. Pulmonary function Bleomycin can cause severe lung injury, including pneumonitis and pulmonary fibrosis, which affects a significant percentage of clients receiving this medication; therefore, pulmonary function is the priority assessment. The client is at risk for CBC changes because bleomycin can cause thrombocytopenia, and is also at risk for decreased kidney function, and the client is at risk for peripheral edema and weight gain due to possible effects on kidney function; however pulmonary function is the priority.

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? 1. Romberg 2. Kinesthetic sensation 3. 2-point discrimination 4. Weber

1. Romberg A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test. Kinesthetic sensation tests the client's ability to identify the position in which the examiner is holding the client's middle finger or great toe. When performing 2-point discrimination, the nurse touches various areas on a client's body with 1- and 2- pointed objects to see if the client can discriminate between 1 and 2 objects. A Weber test is a hearing screening that uses a tuning fork.

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? 1. Sit at the bedside while feeding the client 2. Order pureed foods 3. Make sure feedings are provided at room temperature 4. Offer the client a drink of fluid after every bite

1. Sit at the bedside while feeding the client The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding. If the client is unable to communicate, the nurse should offer the client fluids after every 3 or 4 mouthfuls. However there is not indication that this client is unable to communicate therefore the client should tell the nurse when she would like a drink.

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? 1. Sodium 123 mEq/L 2. Blood glucose 100 mg/dL 3. Potassium 3.5 mEq/L 4. Hemoglobin 13 g/dL

1. Sodium 123 mEq/L A sodium level of 123 mEq/L is below the expected reference range of 136 to 145 mEq/L. Low sodium levels can cause confusion and lead to seizures, coma, and death. A blood glucose of 100 mg/dL is within the expected reference range of 70 to 110 mg/dL for fasting and less than 200 mg/dL for a casual blood draw. A potassium level of 3.5 mEq/L is within the expected reference range of 3.5 to 5 mEq/L A hemoglobin level of 13 g/dL is within the expected reference range of 12 to 18 g/dL

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (SATA) 1. The client's ID number 2. The client's room number 3. The client's name 4. ABO compatibility 5 Rh compatibility

1. The client's ID number 3. The client's name 4. ABO compatibility 5 Rh compatibility Two nurses must verify this information, including the client's facility identification number, name, ABO compatibility, and RH compatibility, to prevent transfusion reactions due to human error.

A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following should the nurse include in the teaching as an adverse effect of lisinopril? 1. Tongue swelling 2. Low potassium level 3. Runny nose 4 Bruising

1. Tongue swelling Angioedema is a fatal response that occurs in about 1% of clients who use ACE inhibitors such as lisinopril. Manifestations of angioedema include swelling of the tongue, lips, or pharynx. ACE inhibitors Lisinopril inhibits the release of aldosterone and can cause potassium retention and hyperkalemia ACE inhibitors can cause a persistent, dry, and irritating cough. A runny nose (rhinorrhea) is not an adverse effect associated with this type of medication. ACE inhibitors can cause adverse effects such as flushing, pruritus, and rashes. However, bruising is not an adverse effect associated with this medication.

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? 1. "You won't need the equipment for very long." 2. "All of this equipment can be frightening." 3. "Why does this equipment bother you.?" 4. "Let me tell you about what each machine does."

2. "All of this equipment can be frightening." This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more. Responding with "let me tell you about what each machine does" does not address the client's concerns about feeling nervous and it changes the subject.

A nurse is providing teaching to a client who has a new prescription for a fentanyl transdermal patch. Which of the following statements by the client indicates an understanding of the teaching? 1. "The patch will not cause constipation like other pain medications do." 2. "I will have to stop drinking grapefruit juice while using the patch." 3. "I will place a heating pad over the patch to boost its effectiveness." 4. "The patch will give me relief from my pain faster than pills can."

2. "I will have to stop drinking grapefruit juice while using the patch." The nurse should instruct the client to avoid drinking grapefruit juice while using the fentanyl transdermal patch. Grapefruit juice can increase the absorption of the medication, raising the amount of fentanyl in the client's blood. This effect can place the client at risk for CNS and respiratory depression.

A nurse is teaching a client who has persistent cancer pain about the adverse effects of opioids. Which of the following statements should the nurse include in the teaching? 1. "Opioids do not relive pain without causing severe adverse effects." 2. "Physical dependence is not the same as addiction." 3. "Tolerance typically means that the medication will no longer be effective." 4. "The most common adverse effect is respiratory depression with prolonged use."

2. "Physical dependence is not the same as addiction." The nurse should explain that physical dependence can occur in all clients who take opioids, and the client may develop abstinence syndrome if the opioid is abruptly withdrawn. Physical dependence is not the same as addiction, but it can result in addiction. Addiction results when the opioid is continued despite physical or psychological harm.

A nurse is providing teaching about benzodiazepines to a client who is discontinuing long-term alprazolam use. Which of the following pieces of information should the nurse include in the teaching? 1. "You might experience somnolence." 2. "Plan to taper the dose slowly over several months." 3. Call the provider if you have muscle weakness." 4. "Confusion is common during this process."

2. "Plan to taper the dose slowly over several months." The nurse should instruct the client to plan to taper the alprazolam dose slowly over several weeks or months to ease the physiological and psychological manifestations of withdrawal. Alprazolam, a benzodiazepine and CNS depressant, can cause drowsiness. The client should call the provider if muscle twitching occurs. Alprazolam can cause muscle twitches and convulsions if it is discontinued too rapidly. Alprazolam can cause confusion if acute toxicity occurs from oral overdose. The client might experience periods of paranoia and delirium if the medication is discontinued too rapidly.

A nurse is caring for a client who has bronchitis and a prescription for a mucolytic agent. Which of the following findings should the nurse identify as an adverse effect of this type of medication? 1. Fluid overload 2. Bronchospasm 3. Electrolyte imbalance 4. Tachycardia

2. Bronchospasm The nurse should identify that bronchospasm is an adverse reaction to a mucolytic agent. Mucolytic agents such as a hypertonic saline solution or acetylcysteine can irritate the airways, resulting in bronchospasm while producing a cough and thinning mucus secretions. A mucolytic agent such as hypertonic saline solution or acetylcysteine can be used for thinning secretions as well as producing a cough in a client who has an upper respiratory infection. Fluid overload is not an adverse effect of this type of medication. Some nebulized medications cause tachycardia, such as beta2-agonist bronchodilators, A mucolytic agent does not cause tachycardia.

A nurse is reviewing the medical record of a client who might have hearing loss. Which of the following data from the client's medical record should the nurse identify as a risk factor for hearing loss? 1. Frequent use of steroids 2. Chronic use of salicylates 3. Intermittent use of antacids 4. Habitual use of laxatives

2. Chronic use of salicylates Chronic use of salicylates such as aspirin can lead to ototoxicity, which can manifest as tinnitus or hearing loss. Glucocorticoids such as corticosteroids are not considered ototoxic; however, they can damage muscles, diminish bone density, and cause visual complications such as cataracts and glaucoma. Antacids are alkaline compounds that neutralize gastric acids. They are not ototoxic and do not cause any specific toxicities. They act primarily on the gastrointestinal tract and can lead to adverse effects like abdominal cramping and nausea.

A nurse is reviewing the laboratory data for a client who has Alzheimer's disease and a new prescription for memantine. The nurse should identify that which of the following findings increases the client's risk for reduced clearance of the medication? 1. Alanine aminotransferase (ALT) 60 international units/L 2. Creatinine clearance 35mL/min 3. HbA1c 5% 4. BMI 31

2. Creatinine clearance 35mL/min Creatinine clearance is an estimate of the glomerular filtration rate (GFR) and the kidney's ability to filter waste. A creatinine clearance of 35mL/min is below the expected reference range of 87 to 139 mL/min and indicates moderate renal impairment. Memantine is excreted by the kidneys, and decreased clearance occurs with moderate renal impairment. Alanine aminotransferase (ALT) is a liver function test. AN ALT of 60 international units/L is above the expected reference range of 4 to 36 international units/L. Elevated levels of ALT indicate hepatic impairment. Memantine is not excreted by the liver; therefore, hepatic impairment does not decrease the clearance of the medication.

A nurse is caring for a client who has been taking metformin for 6 months. Which of the following findings should the nurse identify as an expected therapeutic effect of the medication? 1. Decreased vitamin B12 levels 2. Decreased blood glucose level 3. Abdominal bloating and diarrhea 4. Decreased LDL level

2. Decreased blood glucose level A client who has taken metformin for 6 months should experience the expected therapeutic effect of a decrease in blood glucose levels. Metformin is a non-insulin medication for clients who have type 2 diabetes mellitus. 1. Metformin is an antidiabetic medication used to treat elevated blood glucose levels. It has an adverse effect of decreasing the absorption of vitamin B12 and causing a decrease in vitamin B12 levels. Metformin also can cause adverse effects of abdominal bloating and diarrhea. Statin medications are prescribed to decrease LDL levels not metformin.

A nurse is assessing a client who has AIDS and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider? 1. Nausea and vomiting 2. Decreased hemoglobin 3. Decrease appetite 4. Anxiety

2. Decreased hemoglobin Zidovudine can cause severe anemia and neutropenia from bone marrow suppression, resulting in hematologic toxicity. Nausea and vomiting are adverse effects of zidovudine that should be reported to the provider. A decreased appetite is an expected adverse effect of zidovudine that should also be reported but is not the most urgent finding. Anxiety is an expected possible adverse effect of zidovudine that should be reported but is not the priority.

A nurse is caring for a client who is taking acarbose to treat type 2 diabetes mellitus. For which of the following adverse effects of this medication should the nurse monitor the client? 1. Insomnia 2. Diarrhea 3. Joint pain 4. Polycythemia

2. Diarrhea The most common adverse effects of acarbose, an alpha-glucosidase inhibitor, are gastrointestinal. They include diarrhea, abdominal distention and cramping, and flatulence. Acarbose is more likely to cause sleepiness than insomnia, a headache than joint paint, and anemia than polycythemia because it can decrease the absorption of iron.

A nurse is caring for a client who has atrial fibrillation and is scheduled for cardioversion. The nurse should anticipate a prescription from the provider for which of the following medications for this procedure? 1. Amlodipine 2. Diltiazem 3. Nifedipine 4. Lidocaine

2. Diltiazem The nurse should anticipate a prescription for diltiazem, which blocks calcium channels in the heart and blood vessels, thereby lowering blood pressure. Also, it is an antiarrhythmic medication that is used during cardioversion to treat atrial fibrillation. Amlodipine is a calcium channel blocker. However, it minimally blocks calcium channels in the heart and is not used to treat arrhythmias. Amlodipine is used to treat hypertension or angina pectoris. Nifedipine is a calcium channel blocker that minimally blocks calcium channels in the heart and is not used to treat arrhythmias. It is indicated for hypertension or angina pectoris. Lidocaine is an antidysrhythmic medication used to treat ventricular dysrhythmias.

A nurse is caring for a client who is receiving cefotetan 1 g via intermittent IV bolus every 12 hours to treat a postoperative infection. Which of the following manifestations should the nurse monitor for as an adverse effect of the medication? 1. Disorientation 2. Epistaxis 3. Constipation 4. Jaundice

2. Epistaxis Cefotetan is an antibiotic that affects vitamin K levels, which can result in bleeding and epistaxis. The nurse should monitor the client for bleeding and notify the provider if this manifestation occurs so the medication can be discontinued. Cefotetan may manifest diarrhea. Cefotetan is a second-generation cephalosporin, a class of antibiotics that does not manifest disorientation as an adverse effect.

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? 1. 3+ Achilles reflex 2. Faint pedal pulses 3. Feet warm to the touch bilaterally 4. Capillary refill of <2 sec

2. Faint pedal pulses Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity. A 3+ Achilles reflex does not indicate a risk of impaired skin integrity. Reflex testing provides information about the sensory and motor functions of the neurological system. A 3+ reflex indicates a more active reflex than expected.

A nurse is caring for a female client who has been taking clomiphene to treat infertility. Which of the following findings should indicate to the nurse that the medication has been effective? 1. Decreased serum luteinizing hormone (LH) levels 2. Follicular enlargement and conversion to corpus luteum after ovulation 3. Increased human chorionic gonadotropin (hCG) levels 4. Blocked endogenous release of LH and prevention of premature ovulation

2. Follicular enlargement and conversion to corpus luteum after ovulation The nurse should identify that clomiphene is a medication that promotes follicular maturation and is used in the treatment of infertility. Successful treatment reveals progressive follicular enlargement, followed by conversion of the follicle to a corpus luteum after ovulation occurs. Clomiphene increases serum LH and follicular-stimulating hormone (FSH) levels, which cause follicular maturation. Clomiphene promotes follicular maturation. Medications that stimulate ovulation increase hCG levels. Medications that prevent premature ovulation block the endogenous release of LH. Clomiphene promotes follicular maturation rather than preventing premature ovulation.

A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client? 1. Hold your breath for 10 seconds 2. Hold the mouthpiece 1 to 2 inches in front of your 3. Tilt your head back slightly and open your mouth wide 4. Depress the canister while taking a slow, deep breath

2. Hold the mouthpiece 1 to 2 inches in front of your mouth 3. Tilt your head back slightly and open your mouth wide 4. Depress the canister while taking a slow, deep breath 1. Hold your breath for 10 seconds

A nurse is teaching a client who has a new diagnosis of angina and has a prescription for isosorbide mononitrate 10 mg PO twice daily. Which of the following client statements indicates an understanding of the teaching? 1. I can take my second dose of medication on later than 9:00PM 2. I should change positions slowly when getting out of bed 3. If I miss a dose, I should double the next dose 4. I should notify my provider if I experience a headache while taking this medication.

2. I should change positions slowly when getting out of bed The nurse should identify that isosorbide mononitrate is an antianginal medication that produces vasodilation. Therefore, this medication can cause orthostatic hypotension. Clients should change positions slowly upon rising to minimize the effects of orthostatic hypotension. The client should take the last dose of medication no later than 1900 to prevent the development of tolerance. The client should never double a dose of medication but should take it as soon as possible if they do miss a dose. A common adverse side effect of isosorbide mononitrate is a headache. The client can take acetaminophen or aspirin to treat the headache as recommended by the provider.

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflation the cuff includes which of the following (SATA) 1. Allowing the client to speak 2. Stabilizing the position of the tube 3. Preventing aspiration of secretions 4. Preventing air leaks 5. Preventing tracheal injury

2. Stabilizing the position of the tube 3. Preventing aspiration of secretions 4. Preventing air leaks An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, and keeps air from leaking around the outer portion of the endotracheal tube.

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? 1. The risk of eating disorders increases at this age. 2. The client's basal metabolic rate could decrease. 3. Daily vitamins will become necessary to meet nutritional needs 4. Limiting the intake of fish to once per week reduces cardiovascular risks

2. The client's basal metabolic rate could decrease. The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places the client at risk of weight gain if a healthy diet is not maintained.

A nurse is providing discharge teaching to a client who has been hospitalized for major depressive disorder and has a prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? 1. I will take amitriptyline in the morning because I'll likely have trouble falling asleep if I take it in the evening 2. I will move slowly when I stand up because amitriptyline can cause my blood pressure to decrease 3. I can drink a glass of beer or wine with my evening meal because amitriptyline doesn't interact with alcohol 4. I will avoid foods that are high in fiber because amitriptyline can cause diarrhea

2. I will move slowly when I stand up because amitriptyline can cause my blood pressure to decrease Amitriptyline can cause orthostatic hypotension. The nurse should instruct the client to take precautions to prevent an injury due to a fall while taking amitriptyline. Amitriptyline is a tricyclic antidepressant that has a sedative effect. This medication is often prescribed 3 times daily until a therapeutic dose has been achieved, and then the entire dose is prescribed at bedtime to help the client sleep at night and prevent daytime drowsiness. Amitriptyline should not be taken with other CNS depressants such as alcohol and sedatives because these substances can enhance the adverse effects of amitriptyline. Amitriptyline and other tricyclic antidepressants have an anticholinergic effect and can cause severe constipation as well as dry mouth, blurred vision, and urinary retention.

A nurse is preparing to administer meperidine to a client who is postoperative and reports a pain level of 8 on a scale of 0 to 10. Which of the following routes of administration will deliver the medication with the shortest time of onset. 1. Oral 2. Intravenous 3. Intramuscular 4. Subcutaneous

2. Intravenous The nurse should identify that meperidine giving intravenously has no barriers to absorption because it is deposited directly into the circulatory system. An instantaneous time of onset and absorption gives the client immediate relief. Meperidine ingested orally has an onset of 15 minutes. Oral medications have 2 barriers to absorption; the lining of the gastrointestinal tract and the capillary walls. An IM and Subcutaneous injection of meperidine has an onset of 10 to 15 minutes because the medication must pass through the barrier of the capillary walls

A nurse is teaching a client who has a prescription for chenodiol for the treatment of gallstones. Which of the following client statements indicates an understanding of the teaching? 1. Treatment should last for a couple of months 2. Liver function tests are required while taking this medication 3. I should contact my provider if I experience diarrhea 4. I can continue to take this medication if I become pregnant

2. Liver function tests are required while taking this medication The nurse should identify that chenodiol is hepatotoxic and can injure the liver. Periodic liver function tests are required during treatment. This medication is contraindicated in clients who have a preexisting liver condition. Treatment with chenodiol usually lasts for 2 years. The nurse should instruct the client to take the medication as prescribed by the provider. Chenodiol can cause dose-dependent diarrhea. This is an adverse effect and does not need to be reported to the provider. Chenodiol is classified by the Food and Drug Administration (FDA) as pregnancy risk category X. It is contraindicated during pregnancy.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? 1. Lateral thigh 2. Lower abdomen 3 Mid-abdominal region 4 Medial thigh

2. Lower abdomen After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra. Securing the indwelling urinary catheter tubing to the client's lateral or outside thigh can create tension on the client's urethra which can cause trauma and injury. Securing the indwelling urinary catheter tubing to the client's medial or mid-thigh area can create tension on the client's urethra which can cause trauma and injury.

A nurse is caring for a client who has been in the PACU for more than 1 hour, has a respiratory rate of 9/min, and is difficult to arouse. The nurse should expect a prescription for which of the following medications? 1. Pentazocine 2. Naloxone 3. Naltrexone 4. Butorphanol

2. Naloxone The nurse should expect a prescription for naloxone. This medication displaces opiate medications from receptor sites, reversing the respiratory depression, sedation, and analgesia that opiates cause. Pentazocine is an agonist-antagonist opioid that the nurse should administer to relieve pain. Naltrexone is a pure opioid antagonist that the nurse should administer to a client who has alcohol use disorder. this medication will decrease cravings for alcohol and block the pleasurable effects derived from alcohol. Butorphanol is an agonist-antagonist opioid that the nurse should administer to relive pain.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? 1. Lower medial quadrant of the buttock near the coccyx 2. Side hip between the iliac crest and anterior iliac spine 3. Tissue of the posterior upper arm 4. Lower inner thigh 4 finger-widths above the patella

2. Side hip between the iliac crest and anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is preferred for the intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (e.g. right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. The nurse could select the outer posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections that are <1mL, the nurse may select the deltoid muscle by placing 4 fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is three fingers widths below the acromion process, or about 5 cm (2 in) to administer intramuscular medication using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place a hand below the greater trochanter and the other hand just above the knee to locate the middle portion of the muscle for the injection site.

A nurse is admitting a client who has atrial fibrillation with a heart rate of 155/min. The nurse should anticipate a prescription from the provider for which of the following medications? 1.Atropine 2.Diltiazem 3.Epinephrine 4.Vasopressin

2.Diltiazem The nurse should anticipate the provider to prescribe diltiazem for a client who is experiencing atrial fibrillation. Diltiazem is an antiarrhythmic agent that reduces the ventricular rate in atrial fibrillation. Atropine is an antiarrhythmic agent that is administered to accelerate the heart rate to treat sinus bradycardia Epinephrine is a vasopressor and bronchodilator agent that is administered to treat cardiac arrest and severe allergic reactions that cause anaphylaxis Vasopressin is a vasopressor agent that is administered to treat cardiac arrest and asystole.

A nurse is teaching a female client who has a new prescription for misoprostol to treat peptic ulcer disease. Which of the following client statements should indicate to the nurse that the teaching was effective? 1. "I should avoid taking NSAIDs while using this medication." 2. "Misoprostol is used to treat stress-induced gastric ulcers." 3. "I should avoid becoming pregnant while taking this medication." 4. "This medication is also used to treat dysmenorrhea."

3. "I should avoid becoming pregnant while taking this medication." The nurse should identify that misoprostol is contraindicated during pregnancy and is classified as pregnancy risk category X by the Food and Drug Administration (FDA). It has the potential to stimulate uterine contractions, and the use of misoprostol during pregnancy has been known to cause partial or complete expulsion of the developing fetus. Misoprostol is an analog of prostaglandin E. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin can cause gastric ulcers by inhibiting prostaglandin synthesis. This makes misoprostol an ideal antiulcer medication for clients who frequently take NSAIDs. In the United States, misoprostol's only approved gastrointestinal indication is for he prevention of gastric ulcers. It is not approved for ulcer treatment. Misoprostol has an adverse effect of dysmenorrhea.

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following foods choices made by the client indicate an understanding of the teaching (SATA) 1. Canned peaches 2. White rice 3. Black beans 4. Whole-grain bread 5. Tomato Juice

3. Black beans 4. Whole-grain bread Dried peas and beans, including black beans, are high in fiber. Whole grains consist of the entire kernel and are also high in fiber. Canned fruits, including peaches, are recommended for clients on a low-fiber diet. Fresh fruits contain more fiber. White rice is recommended for clients on a low-fiber diet. Brown rice is higher in fiber. Canned juices, with the exception of prune juice, are recommended for clients on a low-fiber diet.

During a physical examination of a client, the nurse suspects strabismus. Which of the following test should the nurse use to collect additional data? 1. Confrontation test 2. Symmetry of palpebral fissures 3. Corneal light reflex 4. Accommodation test

3. Corneal light reflex The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. this test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses. A confrontation test compares the visual fields of the client with that of the examiner. The palpebral fissure is the space between the eyelids, which is unequal in clients who have ptosis (i.e. drooping of one or both of the eyelids). The test for accommodation determines whether the client's pupils constrict as they focus on an object the examiner brings closer to the eyes.

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? 1. Measure the pulse using a Doppler ultrasound stethoscope 2. Check the client's pedal pulses 3. Count the apical pulse rate for 1 full minute and describe the rhythm in the chart 4. Take he pulse at each peripheral site and count the rate for 30 sec

3. Count the apical pulse rate for 1 full minute and describe the rhythm in the chart If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. Then, the nurse should document the irregularity in the client's medical record. the nurse should use a Doppler ultrasound stethoscope for a pulse that is nonpalpable or difficult to palpate. The nurse should assess pedal pulses to determine circulation in the client's lower extremities. The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? 1. Death is unacceptable under any circumstances. 2. Magical thinking helps avoid thoughts of death 3. Death is viewed as an interruption of what might have been 4. Death is a natural consequence of a deteriorating body.

3. Death is viewed as an interruption of what might have been. young adults tend to see a whole life ahead of them, so death is often seen as interrupting that life. Young adults do not typically welcome death at this time. Adolescents tend to reject the end of life, especially their own. Preschooler tend to avoid thoughts of death by employing magical thinking. Accepting the deterioration of the body is more likely among older adults, some of whom might consider death a relief from chronic or terminal illness.

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client? 1. Make eye contact with the interpreter. 2. Break sentences into shorter segments to allow time for interpretation. 3. Ensure the interpreter and the client speak the same dialect 4. Speak in a loud tone of voice

3. Ensure the interpreter and the client speak the same dialect To encourage effective communication and promote client understanding, the nurse should first ensure the interpreter and the client speak the same dialect. To enhance the nurse-client relationship, the nurse should direct information, instructions, and questions to the client, not to the interpreter. The nurse should make every effort to speak in short sentences but should not break sentence into fragments to allow time for interpretation. The nurse should speak slowly and distinctly and avoid the use of metaphors that might be challenging to translate. The nurse should speak clearly, not loudly.

A nurse is teaching a client who has severe generalized rheumatoid arthritis and is scheduled to start taking prednisone for long-term therapy. The nurse should instruct the client to report which of the following as an adverse effect of prednisone. 1. Thrombosis 2. Immunosuppression 3. Gastric Ulceration 4. Liver Toxicity

3. Gastric Ulceration The nurse should instruct the client to monitor for gastric ulceration as an adverse effect of the long-term use of prednisone. Other adverse effects of this medication include osteoporosis and adrenal suppression. The nurse should identify that NSAIDs can selectively inhibit COX-2 and can increase the risk of thrombotic events The nurse should identify that non-biological disease-modifying anti-rheumatic drugs (DMARDs) can cause immunosuppression The nurse should identify that methotrexate, which is a DMARD, can cause hepatotoxicity.

A nurse is reviewing the laboratory results of a client who is taking a medication and notes that the client's blood tests show an elevated level of the enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The nurse should recognize that these findings are potential indications of which of the following conditions? 1. Renal dysfunction 2. Myelotoxicity 3. Hepatic Toxicity 4. Cardiac dysrhythmia

3. Hepatic Toxicity The nurse should identify that elevated levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are indications the client might be at risk for hepatic toxicity. AST and ALT are enzymes that test liver function. Therefore, this should indicate to the nurse that the medication the client is taking is damaging to the liver. The client should undergo liver function tests, and the nurse should notify the provider of this finding. Some medications can cause kidney injury resulting in dysfunction or failure such as the antifungal medication amphotericin B. For medications that rea toxic to the kidneys, the client should undergo routine urinalysis and have their serum creatinine or creatinine clearance laboratory tests monitored. Myelotoxicity affects the bone marrow. For medications that are toxic to bone marrow, the client should have their complete blood cell counts monitored periodically. QT interval medications can prolong the QT interval, thereby placing clients at risk for seri8ous dysrhythmias. They should be used with caution in clients who are predisposed to dysrhythmias. This can be a potential risk for older adults and clients who have bradycardia, heart failure, congenital QT prolongation, and low levels of potassium or magnesium.

A nurse is reviewing the medical history of a client who has spasticity due to multiple sclerosis and a new prescription for tizanidine. Which of the following comorbidities increases the client's risk of adverse effects while taking this medication? 1 Pneumonia 2. Benign prostatic hypertrophy (BPH) 3. Hepatitis 4. Diabetes mellitus

3. Hepatitis Tizanidine can cause liver damage. This medication should be used with extreme caution in a client who has a preexisting impairment of hepatic function. Tizanidine can also cause urinary rhinitis. Baclofen might cause urinary retention, which should be considered in a male client who has BPH. However, BPH does not increase the client's risk of developing adverse effects while taking tizanidine.

A nurse is caring for a client who has a new prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication? 1. Ecchymosis 2. Jaundice 3. Hypotension 4. Hypokalemia

3. Hypotension Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, can cause hypotension and postural hypotension, especially during the first 3 hours following the initial dosage. Enalapril can cause a decrease in Hgb and Hct, but it does not alter platelets. Enalapril can cause kidney failure but not liver failure or jaundice. Enalapril increases potassium levels and can cause hyperkalemia.

A nurse is teaching a client who has a new prescription for sucralfate for a duodenal ulcer. Which of the following client statements indicates an understanding of the teaching? 1. I should take this medication with my meals and at bedtime 2. I should only have to take this medication for about 2 weeks 3. I should wait at least 30 minutes before taking this medication after I take an antacid 4. I should swallow these tablets whole.

3. I should wait at least 30 minutes before taking this medication after I take an antacid The nurse should recognize that antacids can raise the gastric pH above 4, which can interfere with the effects of sucralfate. To minimize these interactions, sucralfate should be taken at least 30 minutes apart from antacids. Sucralfate should be taken 1 hour before meals and at bedtime for optimal effectiveness. Treatment with sucralfate lasts for about 4 to 8 weeks. The nurse should emphasize the importance of completing the entire prescribed treatment. Sucralfate tablets are large and difficult to swallow but can be broken or dissolved in water before ingestion. Sucralfate tablets do not need to be swallowed whole.

A nurse is reviewing laboratory values for a client who reports fatigue and cold intolerance. The client has an increased thyroid-stimulating hormone (TSH) level and a decreased total T3 and T4 levels. The nurse should anticipate a prescription for which of the following medications? 1. Methimazole 2. Somatropin 3. Levothyroxine 4. Propylthiouracil

3. Levothyroxine Levothyroxine replaces thyroid hormone for a client who has hypothyroidism. Laboratory values for hypothyroidism include an increased TSH level and decreased total T3 and T4 levels. Clinical manifestations of hypothyroidism include fatigue, cold intolerance, and a decreased body temperature and pulse. Methimazole inhibits thyroid production for a client who has hyperthyroidism Somatropin is a growth hormone prescribed for a client who has a growth hormone deficiency of the anterior pituitary gland. Propylthiouracil blocks thyroid production and is a second-line medication used to treat hyperthyroidism.

A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects? 1. Thrombophlebitis 2. Hyperactive reflexes 3. Muscle weakness 4. Hypoglycemia

3. Muscle weakness Chlorothiazide is a thiazide diuretic used to treat hypertension and congestive heart failure. It promotes the excretion of water, sodium, and potassium and can cause hypokalemia. Manifestations of hypokalemia include muscle weakness, muscle cramps, and dysrhythmias. Chlorothiazide can cause hypercalcemia, hypoactive reflexes, and hyperglycemia.

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? 1. Ask the client's neighbor to call a family member to interpret 2. Ask the client's neighbor to translate the information 3. Obtain the services of an interpreter 4. Document the inability to provide discharge instructions

3. Obtain the services of an interpreter

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? 1. Raise the enema bag if the client experiences cramping 2. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion 3. Place the client in a left Sims' position 4. Don sterile gloves prior to the procedure

3. Place the client in a left Sims' position The nurse should place the client into a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg. The nurse should administer the fluids slowly and lower the container for a client who experiences fullness or pain during the administration of the enema. The nurse should lubricate 5.08 cm (2 in) of the tip of the rectal tube prior to insertion. The nurse should don clean gloves to perform an enema procedure for a client.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? 1 Remove the NG Tube 2. Advance the NG Tube quickly 3. Pull the NG Tube back slightly 4. Ask the client to tilt head backwards

3. Pull the NG Tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows. The nurse should ask the client to tilt their head forward to aid the insertion of the NG tube into the esophagus.

A nurse is teaching self-administration of NPH insulin to a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include? 1. Alternate injection doses between the abdomen and the thigh 2. Shake the vial before withdrawing the dosage 3. Rotate injection sites within the same area 4. Discard the vial if the insulin is cloudy

3. Rotate injection sites within the same area To prevent lipodystrophy, the client should rotate injection sites and keep them about 2.5 cm (1 in) apart within the same anatomical area. Because the absorption varies with the site of injection, the client should use the same general area such as the thigh or the abdomen each time. NPH insulin is a cloudy suspension. The client should discard other types of insulin if the solution is cloudy. The client should roll the vial between the palms, not shake it, to resuspend the particles.

A nurse is caring for a client who has heart failure and is taking oral furosemide 40 mg daily. For which of the following adverse effects should the client be taught to monitor and notify the provider if it occurs? 1. Nasal congestion 2. Tremors 3. Tinnitus 4. Frontal headache

3. Tinnitus Loop diuretics such as furosemide can cause ototoxicity. The client should be taught to notify the provider if tinnitus, a full feeling in the ears, or hearing loss occurs. Nasal congestion is not an adverse effect of furosemide Furosemide does not cause movement disorders such as tremors Headaches are not an adverse effect of furosemide. Headaches can occur in a client who has fluid overload, which furosemide might be prescribed to treat.

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? 1. Don sterile gloves 2. use the dominant hand to retract the labia 3. Use the index finger to insert the suppository 4. Ease the suppository along the anterior vaginal wall.

3. Use the index finger to insert the suppository To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. the nurse should wear clean gloves for this procedure, not sterile gloves. The nurse should ease the suppository along the posterior vaginal wall

A nurse is caring for a client who takes warfarin 2.5 mg PO daily and has an INR of 6.2 The nurse should anticipate a prescription from the provider for which of the following medications? 1. Protamine sulfate 2. Fondaparinux 3. Vitamin K 4. Bivalirudin

3. Vitamin K The nurse should anticipate the provider to prescribe vitamin K for a client who has an INR of 6.2 Vitamin K antagonizes warfarin's actions, which can reverse warfarin-induced inhibition of clotting factor synthesis. Protamine sulfate is an antidote that is administered for severe heparin overdoses Fondaparinux is an anticoagulant medication. The nurse should recognize that an anticoagulant should not be administered to a client who is hyper-coagulated. Bivalirudin is an IV anticoagulant. The nurse should recognize that an anticoagulant should not be administered to a client who is hyper-coagulated

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? 1. Place the client in a semi-private room 2. Wear a mask when providing care 3. Wear a gown when in the client's room 4. Dispose of all bed linens used by the client

3. Wear a gown when in the client's room The nurse should apply a gown at all times when in the client's room to maintain contact precautions. This client who has MRSA should be placed in contact isolation, which includes the use of gloves and a gown when providing care. The client should be placed in a private room when a wound is contaminated with a virulent or multi-drug-resistant organism such as MRSA. The nurse should wear a mask when a client has an infection that can be transmitted via airborne or droplet routes. When splashing or spraying of body fluids is anticipated, the nurse will require full-face protection. The nurse should use moisture-resistant single bags to collect linen. The nurse should not overfill and should tie the bag securely to prevent the transmission of microorganisms. the nurse should double bag the initial bag if the outside becomes contaminated. The linens should be properly sanitized and reused.

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? 1. Does the medication you are taking relieve the pain 2. Can you point to where the pain is the worst 3. What do you think caused the onset of your pain? 4. Changing positions makes your pain worse, right?

3. What do you think caused the onset of your pain?

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? 1. "In time you'll know the right thing to do." 2. "I am sorry. Would you like me to call someone for you?" 3. "There are multiple treatment options for you to consider." 4. "Can you explain the concerns you're having right now?"

4. "Can you explain the concerns you're having right now?" This response uses the therapeutic communication technique of asking a relevant question. By using an open-ended question to ask the client to explain any present concerns, t he nurse is encouraging the client to respond and provide additional information.

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? 1. Judgement 2. Short-term memory 3. Attention span 4. Abstract reasoning

4. Abstract reasoning This exercise evaluate higher-level thinking and the ability to understand and interpret abstract thoughts. To test judgement, the nurse could ask what decisions the client would make in response to a specific real-life challenge To test short-term memory, the nurse could ask the client to recall something like a list of 3 words that was provided a few moments earlier to test attention span, the nurse could ask the client to count backwards from 100 in intervals of 7.

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? 1. Did you report the chest pain episodes to your physician 2. Is there a history of heart disease in your family 3. Have you had this pain before 4. Can you tell me what the pain felt like and show me exactly where it was

4. Can you tell me what the pain felt like and show me exactly where it was The nurse should determine that the priority question for evaluating the client's pain is to quantify its characteristics, onset, duration, surrounding events, and location. This will help the nurse determine what action to take next.

A nurse is administering oral hydroxyzine to a client. Which of the following adverse effects should the nurse instruct the client to expect. 1. Diarrhea 2. Anxiety 3. Nausea and Vomiting 4. Dry Mouth

4. Dry Mouth Hydroxyzine has anticholinergic properties. Dry mouth is a common adverse effect of this medication. The nurse should instruct the client to take sips of water or suck hard candies to minimize this effect. Hydroxyzine, an H1-receptor antagonist, is sometimes us3ed to treat anxiety. Anxiety is not an expected adverse effect of the medication. Hydroxyzine has antiemetic properties, thereby reducing the occurrence of nausea and vomiting.

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? 1. From the middle of the thigh toward the wound 2. From the left lower abdominal quadrant toward the wound 3. From the left hip toward the wound 4. From the wound toward the surrounding skin

4. From the wound toward the surrounding skin The nurse should cleanse a surgical wound from the lease contaminated location (the inside of the wound) towards the most contaminated (the surrounding skin)

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider. 1. Tenderness when touched 2. Pink, shiny tissue with a granular appearance 3. Serosanguineous drainage 4. Halo of erythema on the surrounding skin

4. Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (Redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection (e.g. purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider. Tenderness when touched is an expected finding in a postoperative wound that is healing by secondary intention. Severe pain might indicate infection or underlying tissue destruction and should be reported. Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of wound healing. This is an expected finding in a postoperative wound healing by secondary intention. Serosanguineous drainage, which is made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggest infection and should be reported.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend. 1. Sweeping the floor 2. Shoveling snow 3. Cleaning windows 4. Washing dishes

4. Washing dishes Washing dishes requires a low level of activity and is appropriate for this client. Sweeping the floor and Cleaning the windows are both moderate-intensity activity's Shoveling snow is a high-intensity activity

A nurse is caring for a client who has cancer and refuses visitros because of his debilitated physical appearance. Which of the following comments should the nurse make? 1. You look fine to me 2. Nobody expects you to look beautiful in the hospital 3. I understand how you feel. I would feel the same way 4. Would you like to talk about how you feel?

4. Would you like to talk about how you feel?