STUDY BANKS 76-84
A licensed practical nurse (LPN) is caring for a client diagnosed with multiple myeloma who is undergoing radiation therapy. Which side effect should be reported to the registered nurse (RN) immediately?
ELEVATED TEMP Elevated temperature is the first finding of infection. Radiation suppresses the body's production of white blood cells, which increases the risk for infection.
A client is receiving erythromycin 500 mg IV every six hours to treat pneumonia. Which of these findings is the most common side effect of the medication?
NAUSEA Erythromycin is a macrolide anti-infective. Nausea is a common side effect of erythromycin, regardless of the route of administration. You should note that the other options listed are not "common" side effects of most medications.
A health care provider orders digoxin (Lanoxin) 0.125 mg and furosemide (Lasix) 40 mg by mouth every day. The nurse would recommend the client should eat which of these foods on a daily basis?
*************A SLICE OF WATER MELON\ A slice of watermelon is the highest in potassium and will replace any potassium lost by the diuretic. A tomato has high potassium but not as much as a slice of watermelon. The other foods do not have high levels of potassium.
-TRIGEMINAL NERVE IS ?CRANIAL NERVE
-TRIGEMINAL NERVE IS 5TH CRANIAL NERVE
The nurse receives a telephone call from a health care provider who wants to give a telephone order. Which of the following actions should the nurse take? (Select all that apply.)
-VERIFY THE UNDERSTANDING BY READING THE ORDER BACK TO THE PROVIDER BEFORE HANGING UP -RECORD THE ORDER WORD FOR WORD AND SIGN THE ORDER Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" as abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility.
A client who takes warfarin (Coumadin) after coronary artery stent placement calls the health clinic to ask, "Can I take Alka-Seltzer for an upset stomach?" How should the nurse respond?
AVOID ALKA SELTZER BECAUSE IT CONTAINS ASPIRIN Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet medication, will potentiate the anticoagulant effect of warfarin and may result in increased bleeding tendencies.
A nurse is caring for a client who is receiving methyldopa (Aldomet). Which assessment finding would indicate to the nurse that the client may be having an adverse reaction to the medication?
SEDATION Methyldopa (Aldomet) is used to treat hypertension. The nurse should assess the client for alterations in mental status, such as sedation. Other common side effects are dizziness, dry mouth, headache and weakness. These changes should be reported to the health care provider.
A nurse is caring for a 2 year-old child. What should be understood as a major stressor for this child during hospitalization?
SEPERATION ANXIETY Note that a toddler will experience all of these listed stresses. However, separation from parents or the caretaker is the major stressor.
The licensed practical nurse (LPN) is reviewing laboratory results for a client diagnosed with acute renal failure. Which result should be reported immediately to the registered nurse (RN) if noted by the LPN?
SERUM POTASSIUM OF 6 ((( MORE IMPORTANT THATN A BUN LEVEL OF 50) Although all of these findings are abnormal, the elevated potassium is a life-threatening finding and must be reported immediately.
trigeminal neuralgia (tic douloureux) s/s??
SHARP STABBING PIERCING PAIN COMMON WITH MEN 50-60 YRS PAIN COMES AND GOES
During a home visit, the nurse observes the mother of a school-aged child in a long leg synthetic cast using a cloth-covered wooden spoon handle to relieve itching inside the cast. Which response by the nurse is most appropriate?
SUGGEST PLACING AN ICE PACK Because itching is a common and frustrating problem for a person with a cast, it would not be therapeutic to simply remind the mother and child that itching is normal. But using anything to scratch the skin inside the cast is not recommended because this can injure the skin, increasing the risk for infection. Clients may use a hair dryer to help relieve itching, but the temperature must be SET TO COOL or cold. Of the given choices, applying ice (protected by a plastic bag) is the most appropriate. Cool temperaturesCONSTIRCT THE BLOOD VESSELS MINIMIZING ITCHING (just like heat vasodilates and intensifies itching.) Sometimes over-the-counter antihistamines may help relieve itching.
nurse is reinforcing discharge instructions with a client diagnosed with asthma. The client is allergic to house dust mites, which makes the asthma worse. Which instruction would be the most helpful suggestion to help control the asthma?
WASH THE LINENS IN HOT WATER WEEKLY For asthma clients who are allergic to house dust mites, washing the bed linens frequently is an important method of preventing asthma symptoms due to the environment. It is helpful to use mattress and pillow covers that are allergen-impermeable. All bed linens (sheets and blankets) should be washed in hot water weekly at temperatures above 130 F (54 C) to kill the dust mites.
A client has had a total gastrectomy for stomach cancer. Which vitamin deficiency should a nurse anticipate and discuss with the client while reinforcing prior teaching?
VITAMIN B12 Clients who have had all or part of their stomachs removed lose intrinsic factor, which is responsible for the absorption of vitamin B12 into the body. This results in B12 deficiency and anemia A MONTHLY INJECTION IM OR IV WITH BE NEEDED FOR THE RAMINDER OF THE CLIENTS LIFE
A preschooler is admitted for the treatment of chronic lead poisoning. A nurse recognizes that the most serious effect associated with chronic lead poisoning is which finding?
CENTRAL NERVOUS SYETM DAMAGE The most serious consequences of chronic lead poisoning occur in the central nervous system. Neural cells are destroyed by the toxic effects of lead causing many problems with intellect. These may range from mild learning difficulties to mental retardation and even death
A client with spinal cord injury at the C-5 level reports having a "pounding" headache. The blood pressure is 180/120 mm Hg. A nurse should take which action first?
CHECK THE URINARY CATH TUBING FOR KINKING This client is exhibiting findings of autonomic dysreflexia (or autonomic hyperreflexia), which is a medical emergency that occurs in clients with spinal cord injury above the C-6. level in response to noxious stimuli. A distended bladder or bowel is the most common cause of autonomic dysreflexia. Prompt relief of this by draining the bladder, in the case of bladder distention from kinked catheter tubing, will relieve findings. A sitting position will not resolve the problem.
When taking the client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first?
WAIT TWO MINUTES AND RETAKE THE BP AGAIN IN THE SAME ARM It is best to wait two minutes between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two-minute wait and it may not provide a reading for a very low pressure. The nurse should have palpated the brachial artery first, before applying the cuff.
An older adult client with a history of alcoholism is 12 hours post-op. The client calls a nurse and says "Get me out of this boat - the sharks are going to eat me." Which action should the nurse take?
COLLECT DATA ABOUT THE PTS RESP RATE AND PULSE 02 A sudden change in mental status (for example, hallucinations) in any post-op client should trigger a nursing intervention directed toward correcting an abnormal oxygenation status. However, the nurse first needs to collect data about the problem before any intervention. Pu oximetry and respiratory rate and effort would be an appropriate initial assessment
A pyloromyotomy is a surgical procedure to correct pyloric stenosis. Postoperatively, the infant is NPO for about ?MANY HRS
3 to 12 hours.
A caretaker has numerous questions about normal growth and development of a 10 month-old infant. Which characteristic should be of most concern to the nurse?
50% INCREASE OF BIRTH WEIGHT Birth weight should double by 6 months of age, triple at 1 year, and quadruple by 18 months. The other characteristics (HEAD CIRCUM GREATER THAN CHEST/ CRYING WHEN PARENTS LEAVE/STANDING UP BRIELY IN PLAYPEN) are normal for the age of this infant. A tip for answering this question is to recognize that the question being asked is about what would be abnormal for a 10 month-old.
It takes ? -? months to adjust to a lifestyle free of chemical use
9 to 15
Normal core body temperature for newborns is ?
97.7 F to 99.3 F (36.5 C to 37.3 C).
A client is newly admitted with severe injuries from a motorcycle accident. The client's vital signs are BP 120/50, rate 110, respiratory rate of 28 and oxygen saturation 90%. Which of these actions should be done as an initial nursing intervention?
ADMIN THE ORDERED 02 THERAPY This client demonstrates early findings of shock with hypoxia, rapid heart rate and respirations. Oxygen therapy is the most important initial intervention by the nurse. The other interventions are secondary to oxygen therapy.
A client has been receiving heparin for five days and now has an order to begin taking warfarin (Coumadin) in the evening. Which intervention should the nurse take next?
ADMIN THE WARFARIN IN THE EVENING AS PRESCRIBED Warfarin takes two to three days before its anticoagulant effect begins to peak at a therapeutic level. Therefore, the heparin is continued until that point. Warfarin takes two to three days before its anticoagulant effect begins to peak at a therapeutic level. The prothrombin time (PT) or international normalized ratio (INR) is used to monitor the effectiveness of warfarin therapy and heparin will be monitored daily using the activated partial thromboplastin time (aPTT) lab test.
The nurse observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum on a newborn infant. What would be a priority focus when the nurse talks to the parents?
ALCOHOL USE DURING PREGNANCY The identification of this cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Facial abnormalities including small head (microcephaly); small maxilla (upper jaw); short, up-turned nose; smooth philtrum (groove in upper lip); smooth and thin upper lip; and narrow, small, and unusual-appearing eyes with prominent epicanthal folds. The palpebral fissure separates the upper and lower eyelids.
The nurse would expect ? in the first trimester.
AMBIVALENCE (simultaneous and contradictory attitudes or feelings (as attraction and repulsion) toward an object, person, or action)
A nurse is reinforcing information about actions to prevent hypercalcemia to a client diagnosed with metastatic bone disease. Which topic is important for the nurse to discuss with the client?
AMBULATION Ambulation promotes mineralization of bones and can reduce serum calcium levels. During REINFORCEMENTof client teaching, it is preferred that the interventions t MOST PT FOCUSED andLEAST INVASIVE BE EMPHASIZED FIRST. Volume expansion, hemodialysis and diuretics can also all decrease serum calcium levels. If you are unsure of the correct response, you should note that three of the options involve medical, and not nursing, interventions. Ambulation is the only client-centered and nursing response.
The practical nurse (PN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for this practical nurse (PN) to accept?
AN OLDER ADULT CLIENT DX WITH CYSTITS WHO HAS AN INDWELLING URINARY CATH PNs who are reassigned should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. The PNs should not accept an assignment that is beyond their knowledge or skills.
A client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together with the baby at home. The client is exhibiting which emotional reaction to her pregnancy?
ANTICIPATION OF BIRTH Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of an appropriate emotional response in the third trimester. The nurse would expect ambivalence in the first trimester. Normal second trimester emotions include accepting the pregnancy and focusing on fetal development.
nurse is participating in a community health fair. As part of the health promotion process, when should the nurse conduct a mental status examination?
ANYTHING HEALTH SCREENING IS DONE ************ A mental status check is a critical part of baseline information and SHOULD BE A PART OF EVERY EXAMINATION, whether general or specific.
A 75 year-old client scheduled for surgery with a general anesthetic refuses to remove dentures prior to leaving the surgical unit for the operating room. Which approach by the nurse is the most appropriate intervention?
ASK THE PT IF IT WOULD BE PREFFERED TO REMOVE THE DENTURES IN THE OR RECIEVING AREA Prior to surgery, clients may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept. The client may simply be concerned about physical appearance during the trip through the halls of the hospital to the surgical suite.
A nurse manager informs the nursing staff at a morning report that a clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of which process during research?
AUTONOMY Individuals must be free to make independent decisions about participation in research without coercion from others. The key to this question is to notice that each staff member can choose whether to participate in the research study. "Individual choice" only relates to the correct response.
The ?t mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.
Affordable Care Act
A nurse is caring for a hospitalized 12 year-old client diagnosed with hemophilia A. Which intervention should the nurse plan on implementing as a priority?
BLEEDING PRECAUTIONS The risk associated with hemophilia A is hemorrhage because the blood cannot clot properly to stop bleeding. Therefore, the client should be on bleeding precautions. The stool checks would be secondary because prevention is a priority and bleeding precautions are preventive.
Birth weight should ? by 6 months of age, ? at 1 year, and ? by 18 months.
Birth weight should double by 6 months of age, triple at 1 year, and quadruple by 18 months.
A nurse is assigned to a client with Parkinson's disease who is experiencing hallucinations. Which of these medications may have been a contributing factor?
CABIDOPA/LEVODOPA (SINEMET) While it is unclear whether some one-third of clients with Parkinson's disease have dementia, the nurse should ask about hallucinations. Parkinson's disease medications can cause hallucinations when the dosage is too high. The nurse should ask clients and family members about hallucinations (and other adverse effects) during each home care or clinic visit.
TRIGEMINAL NEURALGIA MAIN DRUG TO TREAT
CARBAMAZEPINE ( AN ANTICONVULSANT)
A nurse is assisting in the care of a client with a history of hoarseness and difficulty swallowing for several weeks. The client is diagnosed with laryngeal carcinoma. Which nursing intervention should have priority attention?
COMPARE DAILY WEIGHTS WITH THE ADMISSION WEIGHT Clients with these findings may not get adequate nourishment. An evaluation of the nutritional state can be accomplished by assessing the weight regularly. The client will certainly need to have alternatives to family support for any help through the therapy that may be necessary. Remember Maslow's hierarchy of needs: physiologic needs supersede psychosocial needs.
The licensed practical nurse (LPN) is assisting with the discharge of a client following inpatient treatment for pulmonary tuberculosis. What information would be important for the LPN to reinforce?
CONTINUE MED USE AS PRESCRIBED Clients should understand that they must continue any therapy as prescribed. Early cessation of treatment may lead to the development of medication resistant bacteria. ((MED SHOULD BE TAKEN ON EMPTY STOMACH)
The nurse in an outpatient clinic occasionally makes home visits to a client with a history of substance abuse. When assessing the client's progress, the nurse should recognize that which behavior is the most revealing of the client's commitment to the treatment program?
CONTINUING DRUG USE Continued drug abuse demonstrates a lack of commitment to the treatment program. This fact must be understood by the nurse as part of the disease of addiction.
The nurse is caring for a client who has had a right upper lobectomy. When caring for this client, the nurse understands that pain management will promote which focus of the care plan?
COUGHING AND DEPP BREATHING The priority for this client is effective exchange airway gas exchange and the expelling of mucous. Without effective pain management, this client will be reluctant to move or cough and/or deep breathe. And if clients, in this case do not cough and deep breathe, they may develop atelectasis or even pneumonia.
A client of Hispanic heritage refuses emergency room treatment until a curandero is called. What should the nurse understand about the practices of a curandero?
CURENDEROS USE HOLLISTIC HEALING PRACTICES A curanderos is a traditional folk healer who uses a holistic approach that includes herbs, aromas and rituals to treat the ills of the body, mind and spirit. Many times, the curandero works with traditional health care providers to restore health.
A nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirmation of pregnancy is made by other tests, which date should the nurse determine as the estimated date of delivery (EDD)?
DEC 23 he use of Naegele's rule to calculate the EDD will give an approximate date. This rule is: add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery.
The nurse is collecting data about a 16 year-old's use of coping mechanisms. The teen had multiple serious injuries after a motor vehicle accident. Which characteristics are most likely to be displayed by this teen?
DENIAL/ PROJECTION/ REGRESSION Helplessness and hopelessness may contribute to regressive, dependent behavior. Denying or minimizing the seriousness of the injuries is used to avoid facing the worst situation or consequence of the accident.
A nurse is reinforcing home care to the parents of a child with rheumatic fever. The nurse should make it a priority to emphasize which topic?
DIFFICULTY BREATHING OR SWELLING OF THE LEGS SHOULD BE REPORTED Rheumatic fever can cause damage to the heart valves resulting in signs of heart failure such as fatigue with activity, shortness of breath and fluid retention. These findings should be reported to the provider, as they may represent heart failure requiring medical treatment.
A client diagnosed with schizophrenia has been treated with quetiapine (Seroquel) for one month. Today the client calls the clinic nurse to report increased agitation and muscle stiffness. What other specific findings should the nurse question the client about?
ELEVATED TEMP AND SWEATING Neuroleptic malignant syndrome (NMS) is a rare disorder characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increase in creatine phosphokinase (CPK) levels. This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications.
A 6 year-old child is admitted to the emergency department. The x-rays show a femur fracture near the epiphysis. What information does the nurse understand about long bone fractures in children?
EPIPHYSEAL FRACTURES OFTEN INTERRUPT A CHILD NORMAL GROWTH PATTERN The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it has potential to interrupt and alter growth of the bone.
The nurse is caring for a 4 year-old child. Which behavior should be of the greatest concern to the nurse when caring for a preschool age child?
EXPRESSES SHAME Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt as a toddler.
The nurse is reinforcing information about clozapine (Clozaril). What information about side effects should the nurse emphasize?
EXTREME SALIVATION Clozapine is prescribed for the management of severely ill schizophrenics who fail to respond to standard drug treatment for schizophrenia. There is a significant risk of agranulocytosis and seizure. Many clients who take clozapine (Clozaril) experience extreme salivation and other AUTONOMIC NERVOUS SYSTEM FINDINGS .
According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives (?STAGE?). If they do not, they may become depressed, angry and fear death.
Ego Integrity versus Despair
The client is diagnosed with Addison's disease. What should the nurse understand about the diet of a person with this diagnosis?
INCREASE SODIUM AND DRINK AT LEAST 1.5 LITERS OF WATER EACH DAY In Addison's disease, the adrenal glands do not make enough of the hormone cortisol (and sometimes aldosterone). This RESULTS IN NA WASTING AND K RETENTION. The findings are typically dehydration, hypotension, hyponatremia, hyperkalemia and acidosis. Mineralocorticoids are usually the preferred treatment. Also, fluids and dietary sodium intake should be increased; potassium intake should be restricted. Don't confuse this with Cushing's disease in which sodium intake is restricted.
In the post-anesthesia care unit (PACU) a nurse provides care to a teenage client after an emergency appendectomy. Which finding is an indication that the client may be in an early stage of shock?
INCREASING PULSE RATE An early finding in shock is an increasing pulse rate. The blood pressure does not decrease in shock until later, as the compensatory mechanisms begin to fail.
A nurse assigned to a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis on the plan of care is a priority at this time?
INEFECTIVE BREATHING PATTERN R/T CNS DEPRESSION Respiratory depression is a life-threatening risk in narcotic overdoses.
At 7:30 am, a client diagnosed with type 1 diabetes has a blood glucose reading of 306 mg/dL. The client reports being very hungry and thirsty. After the nurse reports the lab result and the client's comments, what type of insulin should the nurse anticipate to administer?
INSULIN LISPRO (HUMALOG) Insulin lispro (Humalog) is a RAPID ACTING insulin that will help to quickly reduce the client's serum glucose level. Be sure the client's breakfast tray is delivered within 5 to 10 minutes after using any rapid-acting insulin.
A client diagnosed with cystitis has been on oral antibiotics for 72 hours. Which report from the client requires further data collection by the nurse?
I FELT HOT, TOOK MY TEMP, AND IT HAS BEEN ELEVATED FOR THE PAST 24 HOURS Elevated temperature after 72 hours of being on an antibiotic indicates that the antibiotic is not effective in treating the organism causing the infection. The provider should be informed immediately so that a different, more effective medication can be prescribed and so that complications such as pyelonephritis are prevented.
The client needs assistance to insert bilateral in-the-ear hearing aids. What action should the nurse take before inserting the hearing aids?
IDENTIFY THE HEARING AID PROGRAMMED FOR EACH EAR Since hearing aids are customized for each ear, the nurse should make sure the correct hearing aid is inserted in the correct ear (a red dot indicates the right ear.) The volume should be turned down when inserting the devices and adjusted after they are in the ear. Hearing aids should only be cleaned with a soft cloth; water or alcohol can damage the device. The battery door should never be used as a handle.
A nurse is following the plan of care for a 75 year-old client with community-acquired pneumonia who is normally healthy and active. Which action should be most effective for the removal of pulmonary secretions?
INCREASE ORAL FLUID INTAKE Secretion removal is enhanced with adequate hydration, because it thins and liquefies secretions. In an older adult, the amount of fluid intake should be individualized based on the client's size, coexisting conditions and other factors because of the risk of fluid overload and normal fluid intake. Chest physiotherapy is beneficial but is not as important as hydration, and may not be needed in this client who is usually healthy and active.
The nurse is providing care for an infant who has had a pyloromyotomy. Which of these approaches for the first postop feeding is most appropriate?
GLUCLOSE AND ELECTROLYTE SOLUTION *********** A pyloromyotomy is a surgical procedure to correct pyloric stenosis. Postoperatively, the infant is NPO for about 3 to 12 hours. The initial feedings are clear liquids provided in small quantities to provide calories and electrolytes
A nurse is working in a variety of health care settings. Which of these actions is a priority in the prevention of infections in various settings such as acute care agencies, clinics or home settings?
HAND WASHING Hand washing remains the most effective way to avoid the spread of infection. This would be a priority to reinforce to clients and families. Nurses need to wash their hands before and after client care, touching objects in a client's room, after removing gloves, or whenever hands are soiled. Alcohol-based hand sanitizer may be used between washing the hands.
he nurse is reinforcing information about the use of sublingual nitroglycerin. What information about side effects should the nurse emphasize?
HEADACHE The most common side effect is headache, which is related to the generalized vasodilatation.
A polydrug user has been in recovery for eight months. Recently, the client has begun to skip breakfast, has not been eating regular dinners, and has been seen frequenting bars to "see old buddies." What should these client behaviors indicate to the nurse?
HEADED FOR RELAPSE t takes 9 to 15 months to adjust to a lifestyle free of chemical use. Thus, it is important for clients to acknowledge that relapse is a possibility and then to identify early warning signs and actions to take to prevent a relapse.
The nurse caring for a client diagnosed with type 1 diabetes mellitus is discussing the client's medication. What statement made by the client is incorrect and indicates a need for further reinforcement of information?
I ALWAYS MAKE SURE TO SHAKE THE NPH BOTTLE HARD TO MIX IT WELL The bottle should by rolled gently, not shaken. Shaking the bottle results in small air bubbles, which may result in errors when drawing up the insulin in the syringe.
The client is undergoing radiation therapy for Hodgkin's disease. The nurse should recognize that which finding is most likely associated with the radiation treatment?
NAUSEA Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling. Hodgkin's disease is cancer of the lymphatic system. The content of this question is "radiation therapy," not Hodgkin's disease. All options, except one, are associated with this disease and not the radiation therapy.
After talking with a partner, a client is voluntarily admitted to the substance abuse unit. After the second day on the unit the client states to the nurse: "My partner told me to get treatment or we will get divorced. I don't believe I really need treatment but I don't want my partner to leave me." Which response by the nurse would best assist the client?
LETS DISCUSS THE BENEFITS OF SOBRIETY FROM DRUGS AND ALCOHOL FOR YOU Only the correct option focuses on the client and the client's problem (alcohol). This is the best response because it gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety
A nurse is assisting in the exam of a pregnant client in her third trimester. The ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what condition?
MATERNAL HYPERTENSION Pregnancy-induced hypertension (also known as gestational hypertension or pre-eclampsia) is a common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients, resulting in poor fetal growth.
The 54 year old client is scheduled for a coronary angiography. The client's medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate?
MONIOTR SERUM CREATINE LEVELS PRE AND POST PROCEDURE Coronary angiography requires the use of a contrast dye. Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN). Adequate hydration helps maintain renal blood flow and reduces the time the contrast media is in contact with the renal tubules and, therefore, will help prevent CIN. Serum creatinine levels are used to monitor for the development of CIN. Nephrotoxic drugs, such as ibuprofen, should not be used for procedures requiring contrast media. The oral hypoglycemic drug metformin increases the risk of lactic acidosis if CIN were to occur; it should be held the day of the procedure until kidney function returns to baseline (as determined by serum creatinine).
A neonate is having difficulty maintaining a temperature above 98 F (36.6 C) and is placed in an infant warming system (IWS). Which of the following actions will ensure the safety of the neonate?
MONITOR THE NEONATES TEMP CLOSELY When using a warming device the neonate's temperature should be continuously monitored, with the probe securely attached to the skin in an area that is directly in the path of the radiant heat. For safety purposes, the infant's eyes should be covered to protect from the light emitted by the observation lamp.
Several days after a total hip replacement, an 80 year-old client is ambulating in the hallway with a walker. The client is to be discharged later in the day. Which finding documented in the morning nurse's notes requires priority attention by the registered nurse (RN) before the client is discharged?
NEW ONSET OF AGITATION AND CONFUSION Agitation along with confusion may alert the nurse to an alteration in cerebral tissue perfusion, side effects of medications or a new infection such as a urinary tract infection. In older adults, confusion is often the first sign of an infection. This may suggest an embolus to the lung from the lower extremity. Pulmonary embolism, often from a fat embolism, is a more common complication after hip replacement.
BED REST AND COUGH SUPPRESSANTS ARE (GOOD/BAD?) FOR TX OF PNEMONIA?
NON BENEFICIAL- BAD Inactivity would be beneficial only if hypoxia occurs with activity, and cough suppressants should be avoided, as they can prevent clearance of secretions by suppressing the cough.
A client being treated for hypertension returns to the clinic for a follow up visit. The client states to a nurse, "I know these water pills are important, but I just can't take them anymore. I drive a truck for a living and can't stop every 20 minutes to go to the bathroom." During a team meeting, which nursing diagnosis should the nurse suggest?
NONCOMPLIANCE R/T TO SIDE EFFECTS The client kept the appointment and stated a knowledge that the pills were important. The client is unable to comply with the regimen due to the side effects of the diuretics being in conflict with the occupation, not a lack of knowledge about the disease process or medication's importance.
A client treated for depression tells the nurse at the mental health clinic, "I have recently purchased a handgun because I am thinking about ending my life." The first nursing action should be to take which approach?
NOTIFY THE PRIMARY HEALTHCARE PROVIDER IMMEDIATELY The health care provider must be contacted immediately as the client is a danger to self and others. Immediate hospitalization, either voluntary or involuntary, is indicated because this client has a suicide plan involving a gun. The key words in this question are "first nursing action." Remember, when the content of the question is life-threatening or potentially life-threatening, notifying the health care provider is the only correct response.
Erythromycin is a macrolide anti-infective. ? is a common side effect of erythromycin, regardless of the route of administration.
Nausea
? (neck stiffness) is associated with meningitis or a cerebral bleed,
Nuchal rigidity
A nurse is caring for a post-surgical client at risk for the development of deep vein thrombosis (DVT). Which action is preventative and should be reinforced by the nurse?
PERFORM RANGE OF MOTION EXCERCISES AND WALK Mobility REDUCES THE RISK OF DVT In the post-surgical client and in any adults at risk. Clients should perform ROM exercises of the legs while in bed, and they should get out of bed to stand, sit in a chair or walk in the hallway several times a day. It is CONTRAINDICATED TO PLACE PILLOW under the knees because pillows will press against the veins and cause an increase in venous stasis. ANTIPLATELET AGENTSARE NOT DRUG of choice for DVT prevention.LEG MASSAGE AVOIDED as it can dislodge a thrombus causing pulmonary embolism, which is a very serious complication of DVT.
the vertical groove on the median line of the upper lip
PHILTRUM
A client is admitted with the diagnosis of infective endocarditis (IE). History of which finding is most important for the nurse to report to the registered nurse (RN)?
RASH THAT APPEARS SUDDENLY A sudden rash indicates a hypersensitive response and can be the forerunner of more serious responses such as laryngeal edema. It can possibly be due to a severe reaction to a new treatment such as antibiotics that are the main treatment for infective endocarditis.
The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program?
REDUCE READMISSIONS TO THE HOSPITAL Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.
A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial axillary temperature is 95 F (35 C). The nurse should recognize that an infant with this temperature can lead to what complication?
REDUCED ( PAO2) PARTIAL PRESURE OF OXYGEN IN ARTERIAL BLOOD Hypothermia (and cold stress) cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).
The nurse is assisting clients with trigeminal neuralgia (tic douloureux) and their nutrition needs. During home care of these clients, which approach should be taken by the nurse?
REINFORCE THE NEED FOR SMALL MEALS CONTAINING HIGH CALORIE- AND SOFT TEXTURED FOODS If a client is losing weight because of poor appetite due to the facial pain, the nurse can reinforce the need for foods that are high in calories and nutrients. The goal is to MORE NOURISHMENT WITH LESS CHEWING. Reinforce that frequent, small meals be eaten instead of three large meals. To minimize jaw movements when eating, the nurse could suggest pureed or liquid forms of nutrition
The nurse is working in a long-term care setting. Which activity should be most effective in meeting the growth and development needs of the older adult residents?
REMINISCENCE GROUPS According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives (Ego Integrity versus Despair). If they do not, they may become depressed, angry and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity and working through losses.
The nurse is reviewing discharge orders for a client who has been prescribed daily warfarin (Coumadin) for the next six months. Which of these points should be emphasized during the discharge instructions?
REPORT ANY CHANGES IN THE COLOR OF YOUR STOOLS AND URINE The client should notify the health care provider for color changes to stool or urine; blood will make the stool dark brown or black and the urine more of a rusty red color.
FOR HEARING AIDS : a red dot indicates the ? ear.
RIGHT
An 18 month-old toddler is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The priority nursing action should be based on which understanding?
THE MMR VACCINE SHOULD BE GIVEN NOW PRIOR TO THE RENAL TRANSPLANT MMR is a live virus vaccine and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. You will note that two of the responses address the timing of administering the vaccine; however, both the correct response and the question contain the term "MMR."
Vhe premature infant is recently diagnosed with respiratory distress syndrome. What is the infant's greatest need at this time?
TIME TO DEVELOP SURFACTANT IN THE LUNGS Respiratory distress syndrome is primarily a disease related to inadequate lung development and is most common when infants are born prematurely, before fetal surfactant production has started. Surfactant coats the alveolar lining, reducing alveolar surface tension which prevents the alveoli from collapsing. The infant needs time to develop so that surfactant production can begin. Surfactant replacement therapy can also be used to prevent or treat this problem.
A client is admitted to the emergency department during an acute asthma attack. Which finding would be most important to monitor and report to the registered nurse (RN)?
USE OF ACCESSORY RESPIRATORY RESPIRATORY MUSCLES In asthma, inflammation of the airways cause the muscles surrounding the airways to become tight and the lining of the air passages swells. Either wheezing or a cough may be the main symptom. Use of accessory muscles of breathing would be most important as an indicator of severe respiratory distress. Note that all of the findings are associated with an acute asthma attack, but accessory muscle use is a priority because it means that air is having difficulty getting into the smaller airways inside the lungs.
A client experiences hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asks to stay a few hours beyond the visiting time in the client's private room. What would be the best response by the nurse?
YES STAYING THE NIGHT AND ORIENTING THE PT TO THE SURROUNDINGS MAY HELP TO DECREASE THE ANXIETY Encouraging a family member or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.
A client diagnosed with depression is scheduled for electroconvulsive therapy treatments (ECT). One hour before the first treatment is scheduled, the client becomes anxious and states, "I do not want to go through with this!" Which statement by the nurse is most appropriate?
YOU HAVE THE RIGHT TO CHANGE YOUR MIND, YOU SEEM ANXIOUS ABOUT IT CAN WE TALK ABOUT IT? This response indicates acknowledgment of the client's rights and the opportunity for the client to clarify and ventilate concerns. Further exploration or assessment would need to be done prior to notification of the health care provider.
BUSPIRONE
a mild antianxiety tranquilizer that is administered in the form of its hydrochloride
Normal second trimester emotions include ? AND ?
accepting the pregnancy and focusing on fetal development.
A is a\ SEVERE adverse effect associated with PHENYTOIN (DILANTIN) and should be immediately reported to the health care provider.
butterfly-shaped rash on the face (lupus erythematosus)
Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN).
contrast media-induced nephrotoxicity (CIN). SERUM CREATINE LEVELS ARE USED TO MONITOR FOR CIN
Pregnancy-induced hypertension (AKA ? OR ?) is a common cause of late pregnancy fetal growth restriction.
gestational hypertension or pre-eclampsia
Swollen or any overgrowth of tender gums often occurs with the use of PHENYTOIN. The effects can be minimized with WHAT ACTIONS?
good oral hygiene, such as brushing after each meal and flossing once a day, as well as regular visits to the dentist.
? will be monitored daily using the activated partial thromboplastin time (aPTT) lab test.
heparin (aPTT)
Methyldopa (Aldomet) is used to treat ?. The nurse should assess the client for alterations in mental status, such as sedation.
hypertension
PYELONEPHRITIS
inflammation of both the parenchyma of a kidney and the lining of its renal pelvis especially due to bacterial infection
Erikson describes the stage of the preschool child as being the time when there is normally an increase in ?
initiative
Hodgkin's disease is cancer of the ? system.
lymphatic system.
Hearing aids should only be cleaned with a ? water or alcohol can damage the device.
soft cloth;
Insulin glargine (Lantus) and insulin detemir (Levemir) are long-acting or "basal" insulins; they are USUALLY ADMINISTERED ? (WHEN)
usually administered once a day, at bedtime.
The prothrombin time (PT) or international normalized ratio (INR) is used to monitor the effectiveness of ?therapy
warfarin (PT/INR)
