random nclex questions
The nurse recognizes which manifestations as signs of community-acquired pneumonia?
Signs of community-acquired pneumonia include cough, crackles, egophony, tactile fremitus, fever, dyspnea, sputum production, myalgias, and pleuritic chest pain.
what can melatonin do to people using beta blockers
can raise blood pressure; avoid using it
what is a function of the temporal lobe?
decreased hearing
Which nursing task would be appropriate to delegate to an LPN/VN?
obtain a wound culture from a client
when do you give kayexalate?
when potassium is high
What should the nurse instruct a client to avoid when prescribed digoxin?
Black licorice contains a natural ingredient called glycyrrhiza, which can deplete the body of potassium while causing an increased retention of sodium. When the body is depleted of potassium, the activity of digoxin, can be greatly enhanced, resulting in digoxin toxicity.
A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention?
Contact the Department of Health and Human Services.
The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority?
Inform the family and ask them to remove the guns.
How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child?
MMR is given SQ. When administering SQ injections use a 23-25 gauge needle, needle length for infants (1- 12 months) is 5/8", children 12 months and older 5/8" - ¾".
what is an anticholinergic agent that is used for extrapyramidal effects caused by meds such as haloperidol?
benztropine
what is biliary atresia?
bile flow from the liver to the gallbladder is blocked. This causes the bile to be trapped inside the liver, quickly causing damage and scarring of the liver cells (cirrhosis), and eventually liver failure.
how do cataracts present?
blurred vision and a glare from lights
processed meats such as hotdogs and sausages contain?
gluten
What precautions should the nurse plan for when admitting a client diagnosed with measles?
place a surgical mask on the client when transferring to x-ray initiate airborne precautions do not assign non-immune nurses to care for client
what is the appropriate serum lithium level for maintenance?
0.6-1.2 mEq/L
what is an appropriate serum lithium level for acute mania?
1.0 - 1.5 mEq/L
Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood?
Client needs low sodium and increased proteins. Scrambled eggs, sliced turkey, biscuit, whole milk
The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior?
Elevated blood urea nitrogen levels can cause confusion, as urea is neurotoxic.
A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client?
Proper methods of closing eyelids and eye patching.
A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, crushing the tablet and mixing it into 3 ounces of applesauce, the new nurse proceeds to the client's room. What priority action should the supervising nurse take?
Suggest the new nurse reconsider client's developmental needs. Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce new food during an illness.
in what position should the nurse place a client post intracranial surgery?
head of bed elevated 30-40 degrees will facilitate breathing and keep ICP from increasing.
what is the rinne test?
a hearing test, primarily used to evaluate hearing loss in one ear.
what type of drug is phenelzine?
an MAOI
A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment findings should be reported to the primary healthcare provider?
Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions.
After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take?
Tell the nurse that whoever draws up the medication has to administer that medication.
A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate?
The best answer is to have the LPN/VN initiate the assessment and let the RN complete the assessment once he/she has completed the present task. Assessment on the new client should be completed by an RN within eight hours of arriving on the unit. It is acceptable to let the LPN/VN initiate the process. It would be best if a licensed person did a brief initial assessment on the child instead of the UAP. The RN will verify the data.
A nurse has been reviewing current medications prescribed to senior citizens who attend a senior center. Which medications should the nurse include when teaching the citizens that grapefruit and grapefruit juice needs to be avoided?
buspirone, carbamazepine, cyclosporine, enalapril Grapefruit and grapefruit juice are metabolized in the liver by the same enzyme that metabolizes these medications. When the liver has too many substances to metabolize, the enzymes focus on metabolizing grapefruit and ignoring the medication. Because the medication is not being metabolized, it can accumulate to a dangerous level and can lead to intense peak effects.
when you think warfarin what should you think of
INR LEVELS
The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful?
The client should exhale completely before using the inhaler; this response indicates the teaching was effective. The client should inhale slowly and push down firmly on the inhaler when administering the medication, therefore the teaching was effective. The client should rinse the mouth after using the inhaler to prevent thrush.
what is chlorpromazine?
an antipsychotic medication
The son of an elderly diabetic client complains that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly?
1. elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar 2. suggest that the client and family check with primary healthcare provider to see if the medication prescribed has low incidence of hypoglycemic episodes 3. symptoms of hypoglycemia may be averted if the client maintains regular meal schedules 4. check blood glucose levels if client becomes unsteady, has difficult concentrating, or is tremulous.
The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests?
AST is a liver function test. Liver function tests including AST should be monitored before, at 12 weeks after initiation of therapy or after dose elevation, and then every 6 months. If AST levels increase to 3 times normal, atorvastatin should be reduced or discontinued. Atorvastatin may increase alkaline phosphatase and bilirubin levels. Atorvastatin is a lipid-lowering agent/HMG-CoA reductase inhibitor. The expected outcome of treatment with atorvastatin is lower serum cholesterol and triglycerides.
The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client?
bradycardia wheezing decreased hematemesis A beta blocking agent is given to keep the heart rate at about 55 beats/min. Decreasing the heart rate should decrease bleeding. Wheezing is an adverse reaction from propranolol and should be monitored for after administration. A decreased heart rate and blood pressure will help to decrease bleeding. Hematemesis is vomiting blood.
how often should you get a physical?
every 2-3 years when no health issues exist including height, weight, and BMI. routine blood tests, urinalysis, and mental health screening is conducted at this time
The nurse educator has provided education to newly hired emergency department nurses regarding mandatory reporting laws. Which suspected instances provided by the new nurses indicates to the nurse educator that education was effective?
financial abuse of an elder gunshot victim client diagnosed with gonorrhea client diagnosed with west nile virus
The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points?
A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions.
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client?
An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unresponsive client may need suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided.
A client is taking NSAIDs for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood?
Elevated reticulocyte count indicates increased production of RBCs. If a client is chronically losing blood, the body's response is to increase RBC production, so the retic count would increase.
A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do?
The client may have smallpox, which is very contagious. The smallpox can also as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure.
The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate?
The client with asthma has a pattern of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased respiratory rate.
what are the symptoms of b12 deficiency anemia?
anorexia, glossitis, and paresthesia
The nurse is caring for a client taking sprionolactone. Which snack choices would indicate to the nurse that the client understands proper dietary choices while on this medication?
apples and grapes
what is two point discrimination
assesses tactile sense. the ability to discern that two nearby objects touching the skin are truly two distinct points, not one. It is often tested with two sharp points during a neurological examination
The nurse assesses a multigravida who is four hours postpartum. Findings include fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority?
assist the client to void. these findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. a distended bladder will displace the uterus, usually to the right
Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider?
calf muscle irritability facial edema blurry vision hemoglobin of 11 mg/dl epigastric pain there are danger signs/symptoms of pregnancy and need further investigation by the primary care provider. these signs could indicate preeclampsia
give a function of the parietal lobe?
decreased sensation
how does diabetic retinopathy affect vision?
diabetic retinopathy is caused by changes in retinal blood vessels and results in blurred vision and outright impairment in some fields
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained?
lateral When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain.
The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client?
low thyroid clients have constipation so they must increase fiber
what is the earliest EKG change for hypokalemia?
premature ventricular contractions, which can deteriorate into ventricular tachycardia or fibrillation without appropriate potassium replacement
The nurse is caring for a client who is taking an antipsychotic medication for the treatment of schizophrenia. The nurse is told in report that the client has akathisia. What symptom should the nurse expect upon assessment?
reports of restlessness, inability to sit still, and nervous energy indicate akathisia. these symptoms respond poorly to treatment. if possible, the dose of the med may be reduced
The nurse is caring for a client prescribed ondansetron due to postoperative nausea. Which side effect is the nurse most worried about the client experiencing with administration of this medication?
torsades de pointes is a life threatening dysrhythmia which can occur with this administration
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client?
"Are you using any products that contain alcohol?"
A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make?
"Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. "
A suicidal client confides to the night nurse, "I will try again when I get out of this place." What is the nurse's best response?
"What do you plan to do?" The nurse must assess the seriousness of the client's intent. Does the client have a plan and the means? How lethal are the means? Direct questions are appropriate when suicide is a possibility.
The nurse is assessing the injection site of a healthy client who received a Mantoux skin test 48 hours ago. Which finding at the injection site indicates a need for further evaluation?
15 mm induration because an induration of 15 mm or greater is usually considered significant in people who have normal or mildly impaired immunity
how many ml can you give IM
2 ml in the deltoid and thigh muscles 5 ml in the gluteus maximus
The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer?
A family history of colon polyps and/or colon cancer is the greatest risk factor for development of colon cancer. Other factors include increasing age and a low fiber diet of processed foods.
A nurse is educating a client on how to manage diarrhea. Which statements made by the client will indicate to the nurse that teaching has been successful?
All of these statements made by a client are correct. The client should drink at least 8 glasses of water so that dehydration does not occur. Drinking a few glasses of electrolyte replacement fluids a day is recommended. Eat foods with sodium and potassium. Most foods contain sodium. Potassium is found in meats and many vegetables and fruits, especially purple grape juice, tomatoes, potatoes, cooked peaches, and apricots. Increase foods containing soluble fiber, such as rice, oatmeal, and skinless fruits and vegetables. Limit fatty foods. Incorrect: Avoid alcohol and beverages containing caffeine, which aggravates the problem.
What should the nurse include when providing education to a client receiving tetracycline?
Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys.
A client diagnosed with cancer has been losing weight. What should the nurse teach the client regarding methods for improving nutritional needs to maintain weight?
Butter and oils added to foods adds calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter.
The nurse is caring for a male client who presents to the mental health unit following a violent altercation his wife. He has numerous bruises on his face, chest, and back. He has one laceration where she "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation?
Calm The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. She is now calm after the tension has been released.
what are the symptoms of pesticide exposure?
headache, dizziness, and muscle twitching memory loss, difficulty concentrating, mood changes, abdominal pain, n/v, malaise, skin rashes, and eye irritation
What room assignment by the charge nurse is most appropriate for a client with a history of biliary atresia who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)?
in this particular situation, a private room is best due to elevated temperature. this could mean the client has an infection and is contagious
what info should be included in the health promotion plan for parents of toddlers regarding the promotion of adequate bowel elimination in toddlers?
include adequate fiber in the diet through whole grains and fruits increase intake of water daily provide toileting opportunities that are free from distractions encourage the toddler to go to the bathroom at least three times daily
mantoux skin test what clients have a positive tuberculin test reaction
HIV infected clients are considered to have a (+) TB skin test with an induration of 5 millimeters or more An induration of 10 millimeters or more is considered positive in recent immigrants (less than five years) from high-prevalence countries such as Haiti, and in children less than 4 years of age An induration of 10 millimeters or more is considered positive for residents and employees of high-risk congregate settings. An induration of 15 millimeters or more is considered positive in any person with no known risk factors for TB.
A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading?
Heart sounds skin turgor urinary output because they all reflect client's fluid volume status
The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement?
I will wear long sleeves and a hat when I go for my afternoon walks. When taking tricyclic antidepressants such as amitriptyline, the skin may be sensitive to sunburn. Use sunscreens, wear protective clothing and sunglasses.
The emergency department called the LDR to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate?
Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. obtaining vital signs and placing clients on electronic fetal monitors are within the scope of practice of LPN/VN.
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway?
Jaw thrust maneuver This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine
A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs?
Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care.
what are the toxic levels for lithium?
Levels exceeding 1.5-2.5 mEq/L begin to produce toxicity
how do brain tumors affect vision?
increase ICP, resulting in blurring of vision
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client?
Observation and support of ventilation Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis.
A female client has used Depo-Provera injections for birth control for several years. For the past 6 months, attempts to become pregnant have been unsuccessful. What instruction should the nurse provide to the client?
Ovulation ceases with Depo-Provera use. It may take 6 to 18 months to reestablish normal ovulation and menstruation.
Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis?
Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain.
A community health nurse, participating in a health fair, is educating a community group about risk factors for developing varicose veins. What risk factors should the nurse include?
Sitting or standing for prolonged periods of time, obesity, female gender, wearing high-heeled shoes.
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?
i had rheumatic fever when i was 10 years old. After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence.
The previous shift nurse reported to the oncoming nurse a suspicion that a client's central line has developed a fibrin sheath. Which prescription does the nurse anticipate the healthcare provider will prescribe?
if a catheter becomes partially blocked due to a fibrin sheath or loses its blood return, a fibrinolytic is typically prescribed. Currently, alteplase is the only fibrinolytic approved by the FDA to treat thrombotic occlusions.
what is a function of the occipital lobe?
impaired vision
A client who is 36 weeks gestation has been admitted to the labor and delivery area for evaluation due to worsening signs of pregnancy induced hypertension (PIH). The BP upon arrival is 168/96. While being monitored, she reports a sudden onset of severe abdominal pain. Further nursing assessment reveals vaginal bleeding, abdominal rigidity, and a fetal heart rate of 90/min on the fetal monitor. What nursing actions would be appropriate for this client?
The nurse recognizes that the client is demonstrating signs of placental abruption (abruptio placentae), most likely due to the presence of PIH. Due to the risk of shock, the maternal vital signs are checked immediately and continuously monitored. The mother will be aware of the emergent nature of her situation. She will need to be informed of what is occurring and kept informed of the status of the fetus. Accurate measurement of I&O, in addition to assessing the amount of vaginal blood loss, will be crucial in determining fluid volume status. Restlessness and decreasing level of consciousness would indicate poor cerebral perfusion as a result of decreased vascular volume and decreased cardiac output. Fluid and blood replacement would be indicated.
The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed?
The nurse should ensure that the consent form is signed, the lab work is in order, and any ordered preoperative medication is given. The operative site is marked by the person who is ultimately accountable for the procedure and will be present when the procedure is performed. If possible, involve the client in the site-marking process
A nurse receives a client in the post anesthesia care unit following application of a long leg cast to the left leg due to a fractured tibia and fibula. Which interventions should the nurse initiate?
The priority nursing assessment is to check distal pulses in both legs. Decrease swelling and risk of compartment syndrome by applying ice to fracture site. Assess for bleeding. Check for tingling, coldness, numbness, and ability to move toes - neurovascular/sensation checks.
The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do?
The value of 4 is above the usual target range of 2-3. The client should be told to watch for signs of bleeding. Further treatment is indicated.
what is atropine?
This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions.
The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client?
Treat a mild episode with 10-15 grams of carbohydrate.
Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis?
Using a shower chair while showering and performing hygiene will help to save energy. Excessive intake of beverages high in caffeine such as coffee, tea, and colas can increased cardiac workload and myocardial oxygen utilization, thereby decreasing oxygen availability. Stop any activity that causes chest pain, a marked increase in shortness of breath, dizziness, or extreme fatigue or weakness. High sodium promotes fluid volume excess. The client should maintain a low sodium intake. Proper hand hygiene prevents infection.
what signs and symptoms will the nurse look for when monitoring an infant client for dehydration?
amber colored urine fussiness tachypnea no tears when crying
The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client
an individual art project because the client is likely to be most comfortable with the solitary activities
Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?
case manager handles the coordination of client care and oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client
how often should you get a comprehensive eye exam done?
every 2 years is recommended
what vaccines are recommended for older adults?
flu herpes zoster diptheria pertussis pneumococcoal vaccine
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given?
glycopurrolate will decrease secretions in the mouth, throat, airway, and stomach. it is used prior to procedures to decrease the risk of aspiration
After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription?
inform the HCP that this med requires a written prescription. verbal order for antineoplastic agents should not be permitted under any circumstances. these meds are not administered in emergency or urgent situations, and they have a narrow margin of safety
what are the signs and symptoms of ovarian cancer?
irregular menses, increasing premenstrual tension. menorrhagia with breast tenderness, early menopause, abdominal discomfort, dyspepsia, pelvic pressure and urinary frequency flatulence, fullness after a light meal, and increasing abdominal girth are significant symptoms
which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon?
jackson pratt drain has 90 mL of blood. the drainage should be green (bile). blood is a problem and needs immediate intervention
what are symptoms of decreased potassium?
leg pains weakness depressed ST segment and flattened T wave
A nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10,000/mm3. What would be the priority nursing assessment?
level of consciousness The platelet level is at the "panic" level. The client is at risk for a cerebral hemorrhage. Assessing the LOC takes priority because this is the answer that is most life threatening.
a nurse is planning to teach a group of adult males in their 40s about health care promotion recommendations. which recs should the nurse include?
limit alcohol intake to no more than two drinks per day get at least 30 minutes of moderate physical exercise on most days of the week
A client is prescribed phenobarbital to control seizures. Which medication prescribed for the client would the nurse recognize interacts with phenobarbital?
loratidine both of these drugs can cause CNS depression. there is a drug to drug interaction between anti-seizure meds
what is a blakemore tub?
medical device inserted through nose or mouth that compresses against gastrointestinal junction and reduces blood flow to esophageal varices
how often should you do skin exams to check for new moles or changes in moles?
monthly
what is the frontal lobe responsible for?
motor control, ability to speak words, concentration, memory, and judgment
Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority?
notify the primary healthcare provider Severe pain with nausea indicates an increase in intraocular pressure and need to be reported at once. Eye damage can result if not resolved quickly. The HCP may prescribe medications or take the client back to surgery.
which nursing tasks can the RN delegate to an unlicensed assistive personnel
obtain BP of client diagnosed with nephrotic syndrome document the intake and output of a client in acute renal failure perform perineal care of a client who has urinary incontinence
A nurse has just inserted an indwelling foley catheter in a client scheduled for surgery. What should the nurse document?
perineal skin assessment urine quality, quantity, and odor client teaching date and time type catheter inserted
a nurse is planning care for a laboring client who is about to be started on oxytocin. what interventions should the nurse include in plan of care
piggy back oxytocin into main IV fluid so when the nurse discontinues the med, the main IV fluid is quickly resumed. monitor for late decels and stop the IV of oxy in this case watch for contractions that are more than a rate of 1 every 2-3 minutes with each lasting no more than 60 seconds continuous fetal monitoring is needed
what is an appropriate rate for potassium chloride?
potassium chloride should be diluted and administered to infuse at no faster than 40mEq per hour.
you have a 6th month old patient being admitted with acute gastroenteritis. what room assignment is most appropriate?
private room, because gastroenteritis is contagious, so if at all possible, place the child in a private room, so other children would be less likely to contract the gastroenteritis
A child is brought into the emergency department (ED) after accidently ingesting 3 grams of acetylsalicylic acid. Initial assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia. What interventions should the nurse initiate?
since the client has hyperthermia you should 1. provide tepid water sponge bath 2. start an Iv for fluid resuscitation 3. insert an NG tube 4. pad side rails 5. obtain blood gases
A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression?
the client states "i have good and bad days" the client smiles at the nurse while talking about her grandchild the client states, "i am having fewer crying spells"
what is the purpose of recieving methotrexate?
this medication will stop the growth of the embryo to save the fallopian tube
The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time?
twenty four hour diet recall what is she eating? how much? are the calories healthy? this is too much weight
The parents of a 2 year old child diagnosed with autism spectrum disorder (ASD) ask the nurse what led the primary healthcare provider to diagnose this disorder for their child. What behaviors will the nurse indicate as signs of autism spectrum disorder?
twisting preoccupation with objects a personal language they often do not form interpersonal relationships with others, or play well with others
What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy?
use thimble when sewing wear a heavy duty oven mitt for removing hot objects from the over long sleeves should be worn to prevent insect bites shave underarms with an electric razor Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury can cause painful swelling after lymph node removal.
