SATA NCLEX SAUNDERS REVIEW

Which of these clients are most likely to develop fluid (circulatory) overload?

A premature infant A 101-year-old man A client on renal dialysis A client with congestive heart failure

A nurse would expect to note which interventions in the plan of care for a client with hypothyroidism?

Instruct the client about thyroid replacement therapy. Encourage the client to consume fluids and high-fiber foods in the diet. Instruct the client to contact the health care provider if episodes of chest pain occur.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note.

Bright red vaginal bleeding Soft, relaxed, nontender uterus

Transparent (Clear Liquid)

Broth Coffee Gelatin

Which of the following herbal therapies would be prescribed for its use as an antispasmodic?

Chamomile Peppermint oil

A nurse is documenting information regarding a client's care into the computerized medical record. Which of the following actions by the nurse would be appropriate?

Change the password for entering computer files at least monthly. Shred the printout of the nurse's flowchart at the end of the nurse's shift. Use own user name and password when logging into the computer system.

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication?

Depressed respirations Extreme muscle weakness Flushing

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches

A nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia?

Signs of fetal distress High level of maternal anxiety Failure of the fetus to descend Fetal distress, failure to descend, and extreme maternal anxiety are consistent with the findings that occur with dystocia. Progressive changes in the cervix are a reassuring pattern in labor while leaking amniotic fluid is a normal occurrence.

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed?

Administering oxygen Inserting a Foley catheter Administering furosemide (Lasix) Administering morphine sulfate intravenously

A nurse is caring for a client who had a renal biopsy. Which interventions would the nurse include in the plan of care for the client after this procedure?

Administering pain medication as prescribed Monitoring vital signs and the puncture site frequently Testing serial urine samples with dipsticks for occult blood

A nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs additional instruction regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)?

"I should apply the eye drops directly over my family member's pupil." "I need to wipe off the tip of the eye drop bottle with a tissue between administrations." "I have to contact the prescriber if my family member develops a small pupil."

A nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother which of the following?

"The child should not be forced to sit on the potty for long periods." "The ability of the child to remove clothing is a sign of physical readiness." "Waiting until the child is 24 to 30 months old makes the task considerably easier." "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform

Prepare to administer morphine sulfate. Prepare to administer intravenous fluids. Prepare to administer 100% oxygen by face mask. Notify RN

The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia?

Proteinuria Hypertension Generalized Edema

Full-Liquified

Pudding Vegetable juice Pureed vegetables

A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note?

Allows for fetal movement Is a measure of kidney function Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus

A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note?

50 mL of drainage in the drainage-collection chamber The drainage system is maintained below the client's chest. An occlusive dressing is in place over the chest-tube insertion site. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

Metformin

A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.

Disadvantages of spinal anasthesia

A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

A nurse is providing client education regarding symptoms of testicular cancer. The nurse encourages the client to report which symptoms as being associated with testicular cancer?

A grainy mass palpated in a testicle and enlargement of the testes are symptoms of testicular cancer and should be reported.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping?

A member of the local ostomy club will be able to provide realistic encouragement. The enterostomal nurse specialist will be able to provide helpful information to the client. Asking the client to assist with tasks may encourage the client to take on more advanced skills and become more adjusted to the ostomy. Reminding the client about the responsibility for caring for the colostomy and telling the client that infection is a major complication (which is incorrect) will alarm the client.

A nurse is assigned to care for an adult client who had a brain attack (stroke) and is aphasic. Choose the appropriate interventions for communicating with the client

A nurse is assigned to care for an adult client who had a brain attack (stroke) and is aphasic. Choose the appropriate interventions for communicating with the client

The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. What data would the nurse expect to note during the data collection?

A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, a positive Trousseau's sign, diarrhea, seizures, hyperactive bowel sounds, and a prolonged QT interval.

A nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question?

Administer meperidine (Demerol) 25 mg for pain. Restrict fluid intake

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family.

Extend touch and hold the client's or family member's hand if appropriate. Be honest and truthful and let the client and family know that you will not abandon them Encourage expression of feelings, concerns, and fears.

A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse instructs the client to avoid consuming which foods while taking this medication?

Figs Yogurt Aged cheese

Inv for Sickle Cell Anemia

Position for comfort. Avoid strain on painful joints. Apply nasal oxygen at 2 L per minute. Provide a high-calorie, high-protein diet.

A nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which of the following findings would be associated with spinal shock in this client?

Bowel sounds are absent. The client's abdomen is distended. Respiratory excursion is diminished. Accessory muscles of respiration are areflexic. During the period of areflexia that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.

A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which intervention(s) would the nurse perform for this procedure?

Apply intermittent suction while rotating and withdrawing the catheter. Advance the catheter until resistance is met and then pull the catheter back 1 cm. Apply suction for up to 10 to 15 seconds. Hyperoxygenate the client before suctioning.

A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Select the appropriate actions that the nurse should take.

Assess the client's pain level. Check the client's blood pressure. Administer a second nitroglycerin, 0.4 mg, sublingually. Contact the registered nurse.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior?

Assist the client in developing means of setting limits on personal behavior. Follow through about the consequences of behavior in a nonpunitive manner. Be clear with the client regarding the consequences of exceeding limits set regarding behavior. Communicate expected behaviors to the client.

The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection?

Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions?

Check the level of the drainage bag. Reposition the client to his or her side. Place the client in good body alignment. Check the peritoneal dialysis system for kinks.

Which clients are at high risk for metabolic acidosis?

Diabetes mellitus, renal failure, and malnutrition lead to metabolic acidosis by increasing acids in the body

A nurse is caring for a client who has been prescribed furosemide (Lasix) and is monitoring for adverse effects associated with this medication. Which of the following should the nurse recognize as a potential adverse effect

Furosemide is a loop diuretic; therefore, an expected effect is increased urinary frequency. Nausea is a frequent side effect, not an adverse effect. Photosensitivity is an occasional side effect. Adverse effects include tinnitus (ototoxicity), hypotension, and hypokalemia and occur as a result of sudden volume depletion.

Select the interventions that are appropriate for the care of an infant.

Hang mobiles with black-and-white contrast designs. Provide swaddling. Caress the infant while bathing or during diaper changes

Which of the following are characteristics of scabies?

It appears as burrows or fine, grayish-red lines. It is transmitted by close personal contact with an infected person. It is endemic among schoolchildren and institutionalized populations. Household members and contacts of the infected child need to be treated at the same time that the child is being treated.

A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list?

Keep the cast and extremity elevated. The cast needs to be kept clean and dry. Allow the wet cast 24 to 72 hours to dry.

Advatages of spinal anasthesia

Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include onset of anesthesia in 1 to 3 minutes, ease of administration, and absence of fetal hypoxia.

A nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage?

Lactose-intolerant clients should not eat dairy products. Therefore these clients need high-calcium foods from nondairy sources. Tofu, broccoli, mustard greens, and sardines are foods that are high in calcium that do not come from dairy sources. Although milk and cheese are high in calcium, they are dairy products, which lactose-intolerant clients need to avoid.

A nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client?

Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

A client enters the emergency room confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe.

Monitor intake and output. Monitor the vital signs. Monitor the electrolyte levels. Increase water intake orally. Provide a sodium-reduced diet.

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.

Which of the following are components of Kohlberg's theory of moral development?

Moral development progresses in relation to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior In stage 2 (instrumental relativist orientation), the child conforms to rules to obtain rewards or to have favors returned..

A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists

Nizatidine (Axid) Ranitidine (Zantac) Famotidine (Pepcid) Cimetidine (Tagamet)

A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed?

Radiation Chemotherapy Serum sodium blood levels Medication that is antagonistic to antidiuretic hormone (ADH)

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by

Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure

Repaglide

Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals, and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar with her or him at all times.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques?

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse monitors for which side effects of the medication?

Signs of hepatitis Flu-like syndrome Low neutrophil count Ocular pain or blurred vision

A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)?

Skin Inhalation Gastrointestinal

A client who was recently prescribed warfarin (Coumadin) is being instructed on diet changes necessary with this medication. The client reports she enjoys all of these food items. Which items should the nurse instruct the client to limit consuming?

Spinach Salad Mustard Greens Dark green, leafy vegetables such as spinach and mustard greens contain vitamin K, which can interfere with the function of warfarin.

A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list?

Symptom control during periods of emotional stress Normal white blood cell counts, platelet, and neutrophil counts Radiological findings that show nonprogression of joint degeneration An increased range of motion in the affected joints 3 months into therapy

A nurse is preparing to administer an enema to an adult client. Choose the interventions that the nurse would perform for this procedure. Select all that apply.

The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100° F (37.8° C) and 105° F (40.5° C). Solution that is too hot will burn the client, and solution that is too cool will cause cramping.

nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which of the following in the care of the client?

The client who has undergone ORIF will be placed on hip precautions per the surgeon's preference. In general, guidelines the nurse should plan to follow include ensuring the client doesn't bend their hips beyond 90 degrees; ensuring the client doesn't sit or stand for long periods of time; ensuring the client engages in walking and mild exercise to maintain strength; ensuring the client doesn't cross their legs past the midline of the body; and ensuring the client uses assistive/adaptive devices when performing activities of daily living.

A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care.

The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV

hoose the correct guidelines related to narrative documentation.

The nurse uses a black-color ink pen to document, because black ink allows the chart to be duplicated with adequate readability for long-term storage. The nurse always dates and times entries and signs and titles each entry. The nurse provides objective, factual, and complete documentation and avoids subjective, judgmental, and evaluative statements. Quotes are used to relate what the client actually said. The nurse avoids leaving blank spaces on documentation forms, because this allows for an area in which notes can be entered by others at a later time. The recording of information in the client's record must be sequential.

A nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client who had a laryngectomy. Choose the instructions that would be included in the list.

The nurse would teach the client how to care for the stoma depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include avoiding swimming and using caution when showering, avoiding exposure to people with infections, preventing debris from entering the stoma, and obtaining a Medic-Alert bracelet. Additional interventions include wearing a stoma guard or high-collar clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

A client is monitoring a client receiving theophylline (Theo-24) to treat symptoms of chronic obstructive pulmonary disease (COPD). Which adverse effects require immediate consultation with the health care provider?

Theophylline is a bronchodilator. Irregular heartbeats and seizures are signs of toxicity and require immediate health care provider notification. Anxiety and insomnia are common side effects and do not require immediate action. Diarrhea is not associated with theophylline toxicity.

A nurse is reviewing the laboratory results of several clients. Which laboratory tests indicate that the nurse can administer the medication as prescribed?

Therapeutic medication levels include the following: gentamicin, 5 to 10 mcg/mL; digoxin (Lanoxin), 0.5 to 2 ng/mL; phenytoin (Dilantin), 10 to 20 mcg/mL; tobramycin (Nebcin), 5 to 10 mcg/mL; theophylline, 10 to 20 mcg/mL; carbamazepine (Tegretol), 5 to 12 mcg/mL.

A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure?

Time the Siezure Stay with the child Move furniture away from the child

A nurse is assisting with caring for a client with cancer who is receiving cisplatin. Select the adverse effects that the nurse monitors for that are associated with this medication.

Tinnitus Ototoxicity Nephrotoxicity Hypomagnesmia Hypokalemia Hypocalcemia Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan?

To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing intervention(s) would the nurse take

Wound dehiscence is the separation of the wound edges, and wound evisceration is the protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the registered nurse is notified, and he or she then contacts the surgeon immediately. The client is placed in a low Fowler's position, kept quiet, and instructed to not cough. Protruding organs are covered with a sterile, saline dressing. Ice packs are not applied. The treatment for evisceration is immediate wound closure under local or general anesthesia.

A nurse is teaching a client regarding types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse tells the client to consume which of the following fluids?

prune juice, tomato juice, cranberry juice, and water.

A nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Choose the interventions that the nurse would expect to be prescribed for the client.

Encourage coughing and deep breathing. Administer anticholinergics, as prescribed. Administer antacids, as prescribed.

Choose the interventions for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL.

Give the child a teaspoon of honey Prepare to administer glucagon subcutaneously if unconsciousness occurs.

A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which adverse effects of the medication?

Hepatotoxicity Rash

A client is receiving meperidine hydrochloride (Demerol) for pain. Which of the following are side effects of this medication

Hypotension Tremors Drowsiness

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client.

In a semi-Fowler's position With the head in a midline position

When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes?

Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset Decline in visual acuity

A nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate will be prescribed?

Initiate an intravenous line. Maintain nothing-by-mouth status. Administer intravenous antibiotics. Administer preoperative medications.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Select the interventions that the nurse includes when administering this medication

Monitor hepatic and liver function studies. Instruct the client to avoid alcohol. Instruct the client to avoid exposure to the sun.

Choose the interventions that a nurse would include when writing a care plan for a child with hepatitis?

Instructing the parents about the risks associated with taking medications Teaching the child effective handwashing techniques Providing a low-fat, well-balanced diet Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the health care provider. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous because of the liver's inability to detoxify and excrete them. Handwashing is the single most effective measure in control of hepatitis in any setting, and effective handwashing can prevent the compromised child from picking up an opportunistic type of infection.

Iodine

Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone

A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach(es) may be beneficial in controlling the client's ICP from an environmental viewpoint?

Nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include keeping the lighting in the room dim or off, maintaining a calm, quiet environment and avoiding emotional stress and interruption of sleep.

Auranofin (Ridaura) has been prescribed for a client with rheumatoid arthritis. The nurse who is collecting data 2 weeks later interprets that the client may be experiencing the signs of medication toxicity based on what data collection findings.

Observes several mouth lesions Rash noted on trunk and neck Reports a metallic taste in the mouth Purplish blotches noticed on the skin Auranofin (Ridaura) is the one gold preparation that is given orally rather than by injection. Gastrointestinal side effects, including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy, but usually subside in the first 3 months. Early symptoms of toxic effects include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth.

A nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which of the following should the nurse include in the preparations?

Open the distal flap of a sterile package first. Prepare the sterile field just before the planned procedure. void placing items within 1 inch of any area surrounding the outer edge of the sterile field. A dry table that is above waist level is used to set up a sterile field. Moisture will contaminate the sterile field and anything below waist level is considered contaminated, according to the principles of surgical asepsis. The sterile field must be kept in sight at all times, and the nurse should not turn away from it. If this happens, the nurse cannot be sure that it is still sterile. Sterile gloves, not clean gloves, are used. An unsterile item touching a sterile item contaminates the sterile item.

A nurse is assisting in developing a postoperative plan of care for a client following a mastectomy. Choose the interventions that will be included in the plan of care.

Place the affected arm on a pillow. Assess the incision for signs of infection. Monitor and measure drainage in the collection device. Following mastectomy, the arm should be elevated above the level of the heart. Arm exercises should be encouraged. No blood pressure readings, injections, IV lines, or blood draws should be performed on the affected arm. Cold compresses are not used in the postoperative period because of their vasoconstrictive effects. The nurse would also assess the incision and flap for signs of infection during dressing changes and would monitor and measure drainage in the collection device.

A nurse is teaching the paraplegic client measures to promote skin integrity. Which instruction(s) will be helpful to the client?

To prevent pressure ulcers from developing, the paraplegic client should shift weight in the wheelchair at least every 2 hours and use a pressure relief pad. While in bed, the bottom sheet should be free of wrinkles and wetness. The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. Additional general measures include a nutritious diet and meticulous skin care.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy.

Use non-latex gloves. Use medications from glass ampules Keep a latex-safe supply cart available in the client's area. Do not puncture rubber stoppers with needles

The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to administer the drops

Wash hands. Put on gloves. Place the drop in the conjunctival sac. Pull the lower lid down against the cheek bone.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Choose the instructions that would be included on the list.

Wear a supportive non-underwire bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL. Continue to breast-feed if the breasts are not too sore

A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction?

"I need to limit playing football to only the weekends." "I should exercise in the evening to encourage a good sleep pattern." The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity

Which of the following statements indicates an understanding of the necessary dietary modifications of a client diagnosed with chronic renal failure?

"I should avoid eggs, and a bagel is preferable." "I should consume approximately 40 g of protein daily." Protein restriction is necessary in clients with chronic renal failure because urea nitrogen and creatinine are the endproducts of protein metabolism, and clients with renal failure cannot excrete these waste products. Generally, clients with chronic renal failure are placed on 40 g of daily protein restriction. Therefore a bagel would be preferable to eggs in a protein-restricted diet. The client should avoid salt; however, a salt substitute is not an appropriate alternative because salt substitutes contain large amounts of potassium, and clients in chronic renal failure commonly are on sodium and potassium restrictions. Tea and coffee both contain caffeine; therefore one is not a good substitute for the other. Milk contains protein, and its consumption should be curtailed in a protein-restricted diet. The client should avoid salt, and soy sauce contains large amounts of salt.

Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)?

"Side effects include abdominal bloating and flatus." "Take the medication with each meal." "Take some form of glucose if hypoglycemia occurs." "Report symptoms such as shortness of breath or tiredness." Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.

The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include?

"Take pulse rate each day." "Weigh at the same time each day." "Palpitations may occur early in therapy." "Be careful when rising from sitting to standing."

A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care?

Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client

A nurse is monitoring a newborn who was born to a drug-addicted mother. Which of the following findings would the nurse expect to note during data collection for this newborn?

A newborn born to woman using drugs is irritable and is easily overloaded by sensory stimulation. The newborn may cry incessantly and be difficult to console. The newborn would hyperextend and posture rather than cuddle when being held.

TB

A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members have already been exposed. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Activities should be resumed gradually

A client has been prescribed acarbose (Precose) for treatment of diabetes mellitus. Client teaching regarding this medication should include which of the following?

Abdominal cramping is common. Side effects include excessive flatulence. The medication should be taken with each meal. Acarbose (an alpha-glucosidase inhibitor) inhibits digestion and absorption of carbohydrates, and thereby reduces the postprandial rise in blood glucose. To be effective, the medication must be taken with each meal; a full glass of water alone is not enough sustenance. The major adverse effects of acarbose are gastrointestinal disturbances including flatulence, cramps, and abdominal distention. Fatty stools are seen in the client with cystic fibrosis; this is not a side effect of acarbose. Dizziness is an adverse effect and may be a sign of hypoglycemia and is not an expected side effect of acarbose.

Choose the safety measures that should be implemented when working in the newborn nursery

Adhere to standard precautions during delivery and in the nursery. Instruct the parents to not release their newborn infant to anyone wearing improper identification. Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room. Newborn safety, infection prevention, and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines need to be followed to prevent transmission of bacteria and other illnesses to newborns. Following safety precautions to prevent newborn abduction includes footprinting the newborn along with fingerprinting of the mother on the identification card. This also includes placing bracelet identification on the mother and infant prior to removing the newborn from the delivery room. Educating parents to release their newborn only to those wearing proper identification is key in preventing newborn abductions in the inpatient situation. Bassinets are to be 3 feet apart. Nurses who are ill should not be working in the nursery.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism. Choose the interventions that apply in the care of this client.

Administer oxygen. Monitor the blood pressure. Prepare to administer morphine sulfate. Prepare to start an intravenous (IV) line.

A nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which of the following in the plan of care?

Allowing the client sufficient time to eat Providing oral hygiene after each meal Maintaining a suction machine at the bedside

A nursing instructor asks a student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid?

Allows for fetal movement Is a measure of kidney function Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, maintains the body temperature of the fetus, and helps assess kidney because it contains urine from the fetus. The placenta prevents large particles, such as bacteria, from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

A nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists to prepare which medications that will be prescribed to be given within the first hour of life?

Antibiotic ophthalmic solutions are required prophylaxis to prevent ophthalmic neonatorum due to Neisseria gonorrhoeae and are given within the first hour after birth. Vitamin K is administered within the first hour of birth to prevent hemorrhagic disease of the newborn. Hepatitis B vaccine is administered prior to baby discharge. Hepatitis A vaccine is not required. Naloxone is used to treat respiratory depression. Lung surfactant, administered by direct intratracheal instillation, is indicated for prevention and treatment (rescue therapy) of respiratory distress syndrome (RDS).

A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client.

Apply a thin layer of petroleum jelly to the skin surrounding the stoma. Protect the stoma from water. Soaps should be avoided near the stoma. Wash the stoma daily using a washcloth. The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen (Tylenol). The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which intervention?

Assuring that her diet consists of bland, easy-to-digest foods and beverages Making nutritious snacks available anytime Providing meals on an isolation tray that contains plastic utensils

A client taking phenytoin (Dilantin) has a serum phenytoin level of 30 mcg/mL. The nurse would expect to note which signs and symptoms on data collection of the client

Ataxia Nausea Diplopia Nystgmus Central nervous system (CNS) depression, lethargy, ataxia, and nausea are all signs of phenytoin toxicity. Nystagmus and diplopia also occur. Phenytoin toxicity depresses the CNS, thus hyperactive reflexes would not be present.

A nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should:

Avoid applying skin lotion on the day of the test. Remove any necklaces before presenting for the procedure. Mammography is a noninvasive type of radiographic procedure. Therefore the client is advised not to wear jewelry or metal objects on the day of the examination. There is no special dietary preparation. The client should avoid the use of lotions or underarm deodorant on the day of the test. The client's ability to drive will not be affected by the procedure.

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign(s) of pregnancy that the nurse should recognize?

Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions

A nurse is providing client teaching regarding glaucoma. Which of the following are important to include in the teaching plan?

Be sure to report halos of light or increased eye pain to your health care provider. Follow a low-sodium, minimal-caffeine diet with plenty of fiber.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which of the following data specifically associated with this therapy before the initiation of therapy?

Before applying heat or cold therapy, the nurse should collect data related to circulatory status, particularly for the prescribed site. Baseline circulatory status is determined so the nurse can continuously monitor the client before, during, and after therapy. Circulatory status can be monitored by checking pedal pulses, capillary refill, color of the extremity, and temperature of the skin. Condition of the toenails is not directly related to circulatory status. If circulatory status is impaired, the nurse should notify the health care provider before heat or cold application.

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which of the following?

Carrying more oxygen on fetal hemoglobin than maternal hemoglobin Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output Bypassing the fetal lungs to circulate oxygen rich blood Using the fetus's beating heart to pump blood in the circulatory system The fetal lungs do not function for respiratory gas exchange, so a special circulatory pathway, the ductus arteriosus, bypasses the lungs. A small amount of blood circulates through the resistant lung tissue, but the majority follows the path with less resistance through the ductus arteriosus into the aorta. The following three special characteristics enable the fetus to obtain sufficient oxygen from maternal blood: fetal hemoglobin carries 20% to 30% more oxygen than maternal hemoglobin; the hemoglobin concentration of the fetus is about 50% greater than that of the mother; and the fetal heart rate is 110 to 160 beats per minute, making the cardiac output per unit of body weight higher than that of an adult

A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints?

Cerebral angiography Lumbar puncture (LP) Computed tomography

Choose the home care instructions that the nurse would provide to the mother of a child with acquired immunodeficiency syndrome (AIDS).

Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). Frequent handwashing is important. The child should avoid exposure to other illnesses

A nurse is assisting in planning care for a client with Hodgkin's disease who is neutropenic as a result of radiation and chemotherapy. Which should be included in the client's plan of care to decrease the risk of infection?

Clients who are undergoing radiation and chemotherapy are at increased risk of infection and should not be exposed to others with infections. Handwashing is the best means of preventing the spread of infection. Monitoring white blood cell counts will indicate the extent of neutropenia. High protein diets and electrolyte monitoring will not decrease the risk of infection.

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in this client?

Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough especially on arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

A nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease?

Clinical manifestations of Hirschsprung's disease during infancy include failure to thrive, constipation, abdominal distention, episodes of diarrhea and vomiting, signs of enterocolitis, explosive and watery diarrhea, and fever. The infant appears significantly ill. Intolerance to wheat occurs in celiac disease.

A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication?

Constipation Bleeding gums Hyperglycemia Decreased platelet count Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily, and blood glucose levels can elevate when taking phenytoin. Sedation is a side effect of barbiturates, not phenytoin. Ataxia is a side effect of benzodiazepines.

A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list.

Contact the health care provider if the child complains of numbness or tingling in the extremity. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Keep small toys and sharp objects away from the cast.

A nurse is caring for a client with a multilumen catheter and is monitoring for signs of an air embolism. Which clinical manifestations that would be noted in this complication?

Cyanosis Chest pain Coughing A churning "windmill" sound heard over the right ventricle on auscultation All clients with intravenous lines are at risk for air embolism. Because an air embolism can be life threatening, it is essential that the nurse monitor for the presence of chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning "windmill" sound.

A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is accurate regarding depression and the older client?

Depression in an older person is likely to have physical manifestations. Some indications of dementia may actually originate as depression. Suicide is a frequent cause of death among the older population. Depression is treatable in an older client. The nurse should be aware of the implications of depression, such as physical manifestations, the possibility of dementia, and suicide risk.

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should reinforce which instructions to the client?

Diarrhea can occur secondary to the metformin. The repaglinide is not taken if a meal is skipped. The repaglinide is taken 30 minutes before eating. Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes.

A nurse is preparing a client for the administration of a Mantoux skin test. The nurse determines that which body area is the appropriate area for injection of the medication?

Dorsal aspect of the upper arm Away from heavy pigmentation Inner aspect of the forearm

A nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which of the following findings?

Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose Drainage from ear or nose (clear or pink-tinged) is an indicator of the presence of cerebrospinal fluid (CSF), which could be leaking as a result of the skull fracture. Bruising around the eyes (raccoon sign) is also an indicator of basilar skull fractures.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse provide to prevent another crisis from occurring?

Drink plenty of fluids. Wash hands before meals and after playing. Report a sore throat immediately. Sickle cell crisis can be precipitated by cold, dehydration, stress, or infection. Increasing the amount of fluids will reduce the viscosity of blood, thus preventing vascular occlusion. A conscious effort to wash hands can improve the child's health by preventing infection. A sore throat is a sign of an infection and must be reported. It is important to avoid cold temperatures of any kind because this can cause vaso-occlusion. Folic acid avoidance is not necessary. Children need to be encouraged to set their own limits in play.

A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis?

Early onset cough Purulent mucus production Mild episodes of dyspnea Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea

The nurse should be alert to signs and symptoms of adrenal insufficiency in a client following adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes.

Hypotension Mental status changes Weakness Fever

A nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which finding is indicative of a bacterial infection

If a bacterial infection of cerebrospinal fluid is present, test results will indicate a cloudy appearance, pressure greater than 200 mm H2O, protein greater than 15 mg/dL, increased white blood cells, reduced glucose level.

A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim.

Increased risk of hypotension Failure to teach the client adequately Increased need to protect the client Lack of follow-up nursing actions

A nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the health care provider. Choose the warning signs that the nurse places on the list

Facial edema Rapid weight gain Visual disturbances Generalized edema Vaginal bleeding Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, regular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

A nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis?

Fever Sweating Agitation Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur

A nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client?

Full seizure precautions include bedrest with padded side rails in a raised position, a suction machine at the bedside, having diazepam (Valium) or lorazepam (Ativan) available, and oxygen. Objects such as tongue blades are not necessary and should never be placed in the client's mouth during a seizure.

A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures?

Gabapentin (Neurontin) Ethosuximide (Zarontin) Carbamazepine (Tegretol

A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flu-like symptoms. Which recommendation by the nurse is therapeutic?

Get plenty of rest. Increase intake of liquids. Take antipyretics for fever. Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management. Carbohydrates are not necessarily more important than other elements of a healthy diet.

A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which of the following on the handout?

It is a disease that causes mucus formation to be abnormally thick. It is a chronic multisystem disorder affecting the exocrine glands. It is transmitted as an autosomal recessive trait. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs.

A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list?

Jewelry will need to be removed. An informed consent will need to be signed. The procedure will take approximately 45 minutes. Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is told that the procedure takes about 45 minutes. An informed consent is required because the procedure is invasive and is therefore performed by the health care provider. The client will need to remove jewelry and metal objects from the chest area. The client is also told that pretest medications may be prescribed for relaxation.

A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect?

Lidocaine Mineral oil Ether solution A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect?

A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which of the following interventions should be included in the plan of care?

Maintaining bed rest Applying warm compresses to the affected area as prescribed Elevating the affected extremity Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may gradually begin to ambulate

A nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings would the nurse expect to note if JIA were present

Malaise, fatigue, and lethargy Painful, stiff, and swollen joints Limited range of motion of the joints History of late afternoon temperature, with temperature spiking up to 105° F Clinical manifestations associated with JIA include intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue and lethargy, anorexia, weight loss, and growth problems. A history of a late afternoon fever with temperature spiking up to 105° F will also be part of the clinical manifestations.

The nurse would anticipate the use of which medications in the treatment of the client with heart failure?

Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment?

Monitor for hemorrhage. Administer eye medications. Maintain the eye patch or shield. Assist with activities of daily living. Educate regarding symptoms of retinal detachment. An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk postsurgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan

Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage. Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider's prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage, and monitors the client's ability to void and move the extremities.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care?

Monitoring daily weight Monitoring intake and output Monitoring extremities for edema Maintaining a low-sodium diet

A nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care?

Monitoring for changes in mental status Encouraging fluid intake of at least 3000 mL/day Monitoring intake and output The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase the intake of sodium, protein, and complex carbohydrates. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required.

A nurse is preparing to instill an otic solution into the adult client's right ear. The nurse would include which action while performing this procedure?

Pulling the auricle of the right ear upward Pulling the auricle of the right ear forward Warming the solution to room temperature Placing the client in a left side-lying position The dropper is not allowed to touch any object or any part of the client's skin. The solution is warmed before use. The client is placed on the side, with the affected ear directed upward. The nurse pulls the auricle upward and backward and instills the medication by holding the dropper about 1 cm above the ear canal

A nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which of the following would be priorities to include

RIsk for Injury Risk for Infection Risk for aspiration Impaired verbal communication Risk for injury is an important diagnosis because clients with Alzheimer's eventually lose the ability of purposeful movement and to walk (falls, apraxia). Clients are at risk as a result of wandering, potential for burns, poisoning by ingesting bottles of noxious fluids/prescriptions taken incorrectly (amnesia, anomia). Late-stage Alzheimer's death frequently is secondary to infection or choking. Aspiration as a result of choking may be a source of infection resulting from aspiration pneumonia. Impaired verbal communication is also important to consider when planning care for these clients. Clients with late-stage Alzheimer's develop amnesia or memory impairment. Eventually loss of the ability to speak and to process communication correctly and a decreased ability to recognize and name objects (aphasia, agnosia) occur.

A nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included?

Rest Local heat Analgesics

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia.

Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia.

A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which of the following is an appropriate pre-procedure care intervention?

Shave the anticipated entry site. Obtain a signed informed consent form. Inquire whether the client has any allergies to shellfish. Ask whether client has ever experienced an allergy to any contrast media. A pulmonary angiography is not performed in the operating room; therefore it is not necessary that the nurse contact this department. An informed consent form is required. The procedure is explained to the client, and the client is asked about allergies to shellfish or contrast media. Oral ingestion, except for sips of water, is avoided for 4 to 6 hours before the test. After the informed consent form is signed, the nurse shaves and prepares the anticipated entry site.

A nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem?

Standing directly in front of the client while speaking Turning down the volume on the radio or TV when talking Speaking slowly and clearly When communicating with a hearing-impaired client, the nurse stands directly in front of the client or angles the mouth so that sound reaches the client's better ear. The nurse speaks slowly and clearly in a normal tone of voice. Competing noises such as a radio and TV should be minimized. The nurse can use gestures only, as long as they are appropriate and used in moderation. All of these approaches will enhance the communication process and minimize the client's self-consciousness about hearing loss.

A male client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which of the following to prevent barotrauma during takeoff and landing?

Sucking on a piece of hard candy Swallowing a few times Yawning occasionally Chewing gum Clients who are susceptible to barotrauma should do any of a variety of mouth movements to equalize pressure in the ear, particularly during takeoff and landing of an aircraft. These include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver may also be helpful. The client should avoid sitting with the mouth motionless during this time because it enhances pressure buildup behind the tympanic membrane.

A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which of the following signs and symptoms?

Tachycardia Photophobia Red, macular rash Positive Kernig's sign Meningitis is an infection or inflammation of the membranes covering the brain and spinal cord. Signs and symptoms can include a positive Kernig's sign, tachycardia (heart rate greater than 100 beats per minute), a red macular-type rash, and photophobia. Other manifestations include severe headache, stiffness of the neck, irritability, malaise, and restlessness

A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list.

Tea and coffee are restricted on the day of the test. The test will take between 45 minutes and 2 hours. The hair should be washed the evening before the test. Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should provide which information to the mother?

The CD4+ count is used to determine the child's immune status. The CD4+ count is used to identify the risk for disease progression. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. The CD4 count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

A nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking the client's

The early signs of fat embolism include changes in the client's mental status or signs of impaired respiratory function caused by impaired perfusion distal to the site of the embolus

A nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms would the nurse expect to find during the initial data collection?

The initial signs and symptoms of bacterial meningitis include fever, nuchal rigidity, and irritability.

Which information would the nurse provide to the client who will be receiving chemotherapy with doxorubicin (Adriamycin)?

Urine and sweat may turn red. The medication is administered by the intravenous route. Promptly report any signs of bleeding to the health care provider. Alopecia can occur. Cardiotoxicity can occur. Doxorubicin causes cardiotoxicity, and the client should be monitored for this adverse effect. It also causes alopecia and the urine and sweat to turn red. Stool turns white in disorders that block bile secretion, such as cholelithiasis; this does not occur with chemotherapeutic agents. It is administered by the intravenous route. Because of its vesicant properties, doxorubicin can cause severe local injury if extravasation occurs. Bone marrow suppression can occur, and the client should report signs of this adverse effect to the health care provider or caregive

A client is being given a transcutaneous electrical nerve stimulation (TENS) unit to use for relief of chronic pain. Choose the instructions that the nurse provides to the client about the TENS unit

The unit needs to be prescribed by the health care provider. The unit works after attaching electrodes to the skin. The unit will decrease the amount of pain medication needed. The electrodes attached to the unit are placed on the skin around the area of pain. Using this unit will help relieve the pain The TENS unit is a portable system that relieves pain and reduces the need for analgesics. It is attached to the skin of the body around the area of pain by electrodes. It is not necessary that the client remain in the hospital for this treatment. However, this pain relief method needs to be prescribed by a health care provider.

A nurse is attending an in-service education session on the therapeutic use of calcium-channel blockers. The instructor of the session determines that teaching has been effective when the nurse correctly identifies that these medications are used for which disorder(s)?

They are used widely to treat hypertension, angina pectoris, and cardiac dysrhythmias.

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse provides a list of instructions for the client regarding management of care. Choose the instructions that the nurse places on the list

To note the color of blood on each perineal pad To watch for the evidence of the passage of tissue To note the quantity of blood on each perineal pad To count the number of perineal pads used on a daily basis Strict bedrest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the health care provider or nurse-midwife.

A nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse expect to note in the neonate?

Tremors Irritability Hypertension Exaggerated startle reflex Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session?

Tuck pant legs into socks. Wear closed shoes when hiking. Apply insect repellent containing DEET. Cover the ground with a blanket when sitting. Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instruction(s) should the nurse reinforce to the client?

Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious.

A nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which of the following indicates the need to further educate the student regarding collecting this specimen?

When collecting a throat culture, the client is told that the test is performed to help identify microorganisms causing the symptoms. The client is instructed to tilt the head back, and both the tonsillar pillars and the posterior pharynx wall are swabbed. A tongue depressor is used in the collection so that the swab is less likely to contact the normal flora of the mouth. The swab is immediately placed in a labeled culture tube and transported to the laboratory. Asking the client to tilt the head forward and to open the mouth Placing the collection swab initially at the back of the client's throat

A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure

Who have a profound hearing loss in both ears Who received no benefit from conventional hearing aids Criteria for a cochlear implant are bilateral profound hearing loss, the client who communicates primarily by speech, the client who receives no benefit from conventional hearing aids, evidence of strong family and social support, and the client who has realistic expectations of the outcome of the implant