Superset for NCLEX
The nurse should include which instruction when developing a teaching plan for a client who is receiving isoniazid and rifampin for treatment of tuberculosis?
Avoid alcohol because Isoniazid and rifampin are hepatotoxic and the drug should be taken on an empty stomach.
A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant? A. Vital sign changes B. Irritability C. Papilledema D. Vomiting
B R: An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP. Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure on the brainstem slows pulse and respiration.
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included? A. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing. B. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. C. Lie flat on the back, splint the thorax, take two deep breaths, and cough. D. Take several rapid, shallow breaths, and then cough forcefully.
B R: The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? A. BP 110/62 mm Hg, atrial fibrillation with HR 82 bpm, bilateral basilar crackles B. SpO2 92% on 2 L nasal cannula, respirations 20 breaths/min, 1+ edema of lower extremities C. weight gain of 1 kg in 3 days, BP 130/80 mm Hg, mild dyspnea with exercise D. confusion, urine output 15 mL over the last 2 hours, orthopnea
confusion, urine output 15 mL over the last 2 hours, orthopnea R: A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood pressure and heart rate are stable.
The client tells the nurse that she frequently experiences nausea and vomiting after receiving radiation and chemotherapy. The nurse adapts the plan of care to include antiemetics. What is the most appropriate time for the administration of the medication? A. Thirty minutes before therapy begins B. When therapy is completed C. At the same time as therapy D. Immediately after nausea begins
A R: Antiemetics are most beneficial if given before the onset of nausea and vomiting. To calculate the optimum time for administration, the first dose is given 30 minutes to one hour before nausea is expected, and then every two, four, or six hours for approximately 24 hours after chemotherapy. If the antiemetic was given with the medication, or after the medication, it could lose its maximum effectiveness when needed.
The family of a client in rehabilitation following heroin withdrawal asks a nurse why the client is receiving naltrexone. What is the nurse's best response? A. To decrease the client's memory of the withdrawal experience B. To help reverse withdrawal symptoms C. To keep the client sedated during withdrawal D. To take the place of detoxification with methadone
D R: Naltrexone is an opioid antagonist and helps the client stay drug free. Keeping the client sedated during withdrawal isn't the reason for giving this drug. The drug doesn't decrease the client's memory of the withdrawal experience, and isn't used in place of detoxification with methadone.
